By Neil Wright, Consultant CBRE Healthcare, Special to Healthcare Facilities Today

Regardless of delivery model, project teams the world-over use similar success factors to understand individual outcomes in hindsight: time and money. Was the project executed on time and did we make a profit in the process? As the Architecture, Engineering, and Construction (AEC) industry has evolved, so too have the means and methods we use to define successful projects.

The value of nurturing symbiotic network relationships with industry professionals, managing expectations, and other soft skills has made us acutely aware of what it means to deliver a successful project in a connected, competitive market. A new trend has emerged in the last decade that moves us away from common interpretation of more industrialized business models. As social networks have covered the globe in memes and self-promotion, we now not only live and work in the physical world but maintain an online reputation as well.

The shift from hyper-local networks of business relationships to a global stage has come in waves. First was the ubiquitous spread of information through the internet. LinkedIn and other social networks now highlight the need for constant self-reflection and digital maintenance – how many “likes” and connections have reinforced your online reputation today? Interestingly, the AEC industry has recognized this digital platform as an opportunity to share information just as other industries once championed (e.g. marketing, design). This is good, as it has come just ahead of the second wave of change: improvement.

Simply put, we have recently (circa 2008) become accustom to doing more with less. Healthcare facilities in particular must now reestablish life cycle cost analyses as a primary vehicle to cut energy costs wherever and whenever possible. Gone are the days of abundant capital facility projects; welcome to the age of capital improvement projects. Healthcare owners want to know how to improve what’s existing before building anew. Our approach to meet these needs must reflect the times.

Traditional project delivery structures have served the industry well for decades. In the way previous shifts have moved the design and construction sectors forward (think earliest master builder to modern construction manager), our industry is now witness to yet another dramatic shift in its evolution. Thanks to the aforementioned access to technology, we now see how antiquated project delivery methods fail to meet the needs of today’s market.

Owners’ demands require solutions that utilize immediate access to real-time data, dynamic information systems, and integrated teams working collaboratively with tools proven to improve upon the industry norm. These waves are upon us, and the most successful in our industry recognize the need to understand how such change will impact our business.

An industry averse to change

It should come as no surprise that our industry is one averse to change. Silos aside, we operate as independent subject matter experts contractually aligned (albeit temporarily) to achieve a shared goal. Again, the success factors remain the same: faster, cheaper, better. It’s no wonder why project teams recite RFI logs ad nauseam, while Integrated Project Delivery (IPD) is still just industry “buzz”. Nevertheless, here we are. The AEC industry has begun to recognize the value of integration and eliminating waste, even if some of those concepts are misconstrued vis-à-vis “The Toyota Way” and a tendency to butcher select Japanese words. It’s a start.

Construction at its core is a supremely dysfunctional array of trade-level innovation and antiquated supply chain behavior constantly vying for self-improvement. To focus solely on the individual misses the bigger picture. We need to better understand how groups – the project teams coordinating the work – execute solutions to complex challenges. This is where we see the puzzle pieces fit together. How do innovative approaches to capital project delivery compliment organizational behavior? Aligning project teams around improved methodologies (i.e. lean techniques) is simple, so long as you don’t say anything about aligning the project team around improved methodologies.

Project delivery models come in various sizes and flavors, this we know. Yet to be explored is the dynamics of change and the implications on the teams that deliver these projects. Laggards though we may be, the adoption of certain technology, ideas, or project delivery frameworks within which integrated teams can collaborate using new technology and ideas is the impending reality we are beginning to warm up to. Understanding how project teams react to change can better prepare our industry to embrace once formidable concepts like integration, accountability, and risk-sharing. So then, before we turn our attention to the change agents themselves, we should briefly explore adoption behaviors typical of the AEC industry.

Understanding the adoption rate of a particular generation, industry, or project team can be achieved in terms of the technology we use regularly in our daily lives. For instance, millennials typically have no problem picking up a new software or application and discovering its integration into school, work, or play with relative ease.

Conversely, those slow to change (either by force of habit or aversion to risk; in other words, a self-reinforcing sense of comfort to keep the status quo or avoid the unfamiliar) are among the baby boomers who have years of successes and failures that establish the “tried and true” way of things. The early adopters camp out in line to purchase the latest product, if only to be among the few who can say “I have that” first. Individual user preference will determine whether you are first among peers to use new software or wait until others sniff out the bugs and adopt a well-oiled, pre-vetted product or service. Suffice to say, we can all agree on where we live within this spectrum as individuals. However, to place the AEC industry as a whole is a trickier task.

Construction trades are slow to adopt a new standard, method, or tool (handheld or virtual). Refer to the aforementioned silo mentality that drives traditional success factors for these skills: the common denominator being the personal pronoun “I”. Adoption rates of individuals are faster, but they can abandon innovations just as easily.

The opposite logic applies to groups. A collective whole [project team] will adopt new innovations at a rate equal to the number of peers subscribing to the same practice. Think of Everett Rogers’ famous adoption curve as a roller coaster: it’s much easier to wait until the change agent has momentum built from the early majority before attempting to explore new grounds. The fall is much easier than the climb.

Put into context, we can understand why healthcare owners hesitate to green light formal tri-party contracts for a major capital [facility] project. It hasn’t been vetted to the point of self-assurance. Design-build has only recently become a sort of benchmark of aligning project stakeholders early. Now we are seeing interest in even earlier team member integration. Change takes time, particularly when you consider the project duration of hospital construction includes conceptual design and facility activation. So how can healthcare owners faced with a seemingly insurmountable challenge of new campus construction or infrastructure upgrades align a project team around concepts that set the organization up for success? Healthcare owners must understand how lean has come to impact the project delivery process. Lean tools and methodologies have a proven track record in manufacturing, and now all eyes are on healthcare.

Construction is easy. More complicated is the human behavior that influences the performance of others in a group setting. Building the team around the right framework is paramount to successful projects. Early integration of designers and contractors is a fundamental motive of IPD. But how can we predict the behavior of those sitting at the table together for the first time? How will the visionary healthcare owner be rewarded for attempting a new approach to an old system? We gain perspective by analyzing the very tools and methodologies which apply pressure against the norm. It is these tools     and concepts that act as change agents steering the construction industry towards a leaner future.

IPD has received accolades elsewhere as a result of its success, and this article won’t explore the delivery model any further than to acknowledge its positive impact. A more interesting question is this: why is IPD so great?

To reiterate a common success factor – align the team early. Moreover, equipping these once disparate stakeholders with tools and systems that encourage collaboration will bring tangible value to every phase of the project. Align the project team around a mutual understanding of success in order to maintain focus on the owner’s needs and organizational goals; this is the voice of the customer. Notwithstanding a formal tri-party agreement, project guardrails should be set early enough in the conceptual stages to instill a sense of trust. You do not need a contract to foster collaboration. In fact, a traditional carrot and stick approach to human nature undermines the mutual trust we need in managing the adoption of new project delivery models.

Change agents

The following paragraphs are meant to serve as only an introduction to specific change agents that are currently improving the way we execute healthcare projects. Each tool can be thought of as a system by itself – systems thinking bolsters the understanding of these ideas. However, it is the combined use of these tools that affords the greatest impact to how we not only deliver projects, but ultimately deliver care.

Glenn Ballard developed the concept of a Last Planner System as a means to bring targeted controls of work production to the construction industry. It has since evolved throughout the Lean Construction Institute and its affiliates who practice lean. With pull planning steadily becoming a more common scheduling methodology across the board, we are seeing more and more contractors adopt this as a foundation to project planning. “Pull” mentality, as opposed to the traditional “push” logic (e.g. Critical Path Method), utilizes another lean concept which values just-in-time delivery by way of constraint adherence.

In other words, pulling allows work (materials, information) into a process only if the process is capable of doing that work (Ballard 2000). Conversely, traditional schedules start from the first task and push subsequent activity based on duration, with little to no reflection. The Last Planner System (LPS) allows teams to measure performance based on focused, well-defined commitments. Any variance in expectations is tracked on a weekly basis to provide a clear history of stakeholder accountability. Root causes can then be determined with further inquiry (i.e. “5 Whys”).

In summary, the LPS captures comprehensive pull schedule logic into a weekly production management framework by way of detailed lookahead schedules. Experience has proven the importance of adoption and diligent conformance to the LPS at the beginning of a project; attempting to migrate to LPS any later will only create confusion. The system can be complex in its makeup and maintenance, but adaptations can undoubtedly provide tremendous value to capital projects of various scope and size.

What the LPS does for production management through pull planning and accountability, the A3 does for problem solving. A3 thinking lends itself to thorough analysis of a current state and the different countermeasures that could improve upon it. It documents a change or improvement that a team will make together. A3 thinking is a change from traditional decision making because of its methodical flow of logic.

First defining the background and business case will help focus the team on the actual problem or question. Then spell out the goal and anticipated future state using proposed countermeasures. Implementation is only successful through accountability and follow though – a concept that can backfire if the team is not centered around clear objectives. Here again we see a powerful lean tool as change agent.

How your project team will come to use A3s depends on how the team is aligned. Set the expectation that all stakeholders (owner, users, designers, contractors, etc.) have ownership in the decision making process and you will find increased input leads to increased production. And not just construction level production; A3s will help identify improvement opportunities within other levels of the organization like administration and nursing or other staff.

Other lean tools are currently being used successfully on healthcare projects. For example, Target Value Design (TVD) is changing the way design teams approach the typical design, estimate, value-engineer, re-design process. To change the fundamental approach to design is to change the interaction between architects and others.

How can we better anticipate the behavior of project teams under a more streamlined process? Consider the additional coordination we’re asking of once isolated team members. Integrating the owner and end users into the design process presents additional layers of coordination and translation of industry jargon.

Put yourself in the seat of unit nurses new to schematic design: how can we expect to extract valuable user input at such a critical stage of the project? Add to that the different lean tools with a learning curve all their own. Have a champion from within the hospital that serves as a shepherd for these new ideas, as you will undoubtedly be met with a little confusion and a lot of questions.

Implement TVD the same way you would LPS or A3 thinking – with education. Know that while trade professionals may be slow to turn onto something new, human nature naturally seeks improvement. Easier is better. Sam Bowles’ work explored the relationship between equity and collaboration. We learned how collective thought can promote a sense of shared well-being at the expense of self-interest.

In a recent letter to the Lean Construction Institute, Greg Howell used the example of a dinner party to exemplify this idea – “the sort of thing that happens when you agree to split a check at a restaurant. Individual behavior depends on the size of the group, the length and nature of past relationships, past ordering practice, the likelihood of another such evening [dinner], and who had the salad and who ordered the expensive bottle of wine. Future dinners or long-term relationships can be challenged when someone takes advantage” (Howell 2013). So while we seek improvement, we are also acutely aware of the actions of others. Used properly, lean tools can certainly afford incredible results. Misused, however, and the team begins to question the tools, not themselves.

Conclusion

Healthcare reform is by law changing the way we deliver care across the country. And while no law dictates that we change the way project teams are assembled to achieve greater results, we have the tools to do so. The status quo is no longer acceptable in the current climate. Technology has allowed us to share information like never before in history. 

We need to understand how these change agents impact the behavior of integrated teams and the individuals that make them. A team dedicated to designing and building the world’s most complex healthcare facilities needs to be trusted with new, lean techniques. More important, however, is understanding how your own team will react to these changes. Do not add another tool or process for the sake of “innovation”. It is far better to prioritize the voice of the customer: owner, contractor, caregiver, patient. If we can anticipate adoption behaviors of those in the AEC industry, owners will reap the benefits of lean systems that take full advantage of technology while maintaining the humanity that builds trust.

Neil Wright is a consultant for CBRE Healthcare