Collaboration in health care construction

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It's been said that the one thing that construction and health care have in common is the ability to use resources quickly. This may be true, but it may be more productive to note that both require collaboration amongst all parties for successful outcomes.

This can be challenging in construction and design, particularly depending on the procurement method used and the participants involved.  The idea of collaboration is easy to conceptualize, but takes effort to achieve the needed results.

Collaboration challenges

Nobel laureate Dr. Daniel Kahneman noted in a National Public Radio interview  “…. There [are] natural stresses in collaboration. The world is not kind to collaboration.” Kanheman went on to note that collaborators often are challenged to validate the need for partnerships over working independently, since collaboration can be costlier and more time consuming.

In addition to outside pressure, partnerships often have to navigate team dynamics and the perception of effort expended by their fellow collaborators.

With the effort required to successfully collaborate, it is easy to question the need to collaborate in construction when, for years, projects have been successfully completed without special frameworks to incentivize collaboration.

This assumption should be questioned on two fronts: 1) project completion studies comparing cost and schedule outcomes from the Construction Industry Institute (CII) have shown 60 percent of projects being on or under budget had above average group cohesion and 70 percent of projects delivered late had below average team integration; and 2) as construction and design become more complex and fragmented, as is the case with health care projects, additional effort is required for project success.

The construction and design industry has been transitioning from less cooperative methods of project delivery, to those that allow and emphasize varying forms of collaboration. This transition from traditional methods like design-bid-build to more collaborative methods like construction manager at risk (CMR) or integrated project delivery (IPD) has been ongoing since the 1970s. Though this transition to more collaborative delivery methods has been ongoing, collaboration doesn’t have to begin and end by the contract alone.

Delivery methods do not predict project success, and many of the tools commonly associated with more collaborative delivery methods can be used on other project types, such as establishment of conditions of satisfactions, pull-planning, targeted value design and co-location of project teams, to name a few.

What does drive project success, as shown by Rybkowski et al., in a presentation at the 20th Annual Conference of the International Group for Lean Construction, is that collaborative project delivery systems produce more reliable outcomes when the delivery systems promote team integration and group cohesion, as noted by the previous CII research. 

To realize these outcomes, it may not be necessary to utilize a contract specific to collaborative delivery, but it may be easier and advisable. Research conducted by the authors of this paper for a presentation at the 2018 Construction Research Congress noted that traditional contract hierarchies and the communication associated with these contract types can challenge participants to be fully engaged and enable them to provide the effort necessary for success outcomes.

This research utilized a survey sent to project participants of two collaborative health care projects, with one using a CMR contract and the other using a multi-party contract typically utilized for IPD-type projects. Findings note that the impacts to productivity were higher than when compared to traditional contract types for both the multi-party contract and CMR, but the project that utilized the contract specific to IPD realized a higher impact to productivity overall.

Project team members surveyed perceived a collaborative/integrated contract as having a beneficial impact to the project compared to a more traditional contract, but noted that to achieve these results additional effort was required.

The additional effort needed for project success is interesting, as project owners are looking to incentivize effort (a common practice in IPD projects, via a risk/reward pool) to encourage project team interactions necessary for successful project outcomes.

Effort is not intended to be a euphemism for productivity or additional labor, as confirmed by the authors’ research presented at the 2019 Associated Schools of Construction Conference, where a project survey revealed that project participants acknowledged effort as being different from labor and productivity.

Effort can mean different things to different people but, in terms of collaboration, it is helpful to view effort as some aspect of a unit-based metric and that of a behavior and/or personnel motivation evaluation. Establishing this difference is helpful when trying to incentivize and monitor key performance indicators for collaborative based projects.

In addition to setting up a project with the right framework, collaborative projects require additional scrutiny of proposed personnel.

Proposed personnel need to be capable of communication that is less formal, and willing in addressing design and construction issues that would typically be avoided in a traditional delivery method.  Further, project participants need to be engaged and actively involved with different aspects of a project and not just their own scope of work.

These qualifications demand team members have a level of broad sophistication and willingness to collaborate beyond what is required with a typical design-bid-build project. This is an important point:. the more collaboration that is needed, the more complex the roles and responsibilities of team members become.

Whether the project is CMR, design-build or IPD, a higher level of collaborative effort is needed from project team members to actively and cross-participate in the design and construction process to achieve a successful outcome.

Highly collaborative project

No matter the delivery method, successful construction projects almost always employ some aspect of collaboration. Projects that have adversarial relationships add layers of complexity to projects and produce waste in navigating these relationships.

The effort that is needed is difficult to employ and, at times, difficult to keep up. Kahneman noted this in his book Thinking, Fast and Slow by saying “A general 'law of least effort' applies to cognitive as well as physical exertion. The law asserts that if there are several ways of achieving the same goal, people will eventually gravitate to the least demanding course of action. “

In a highly collaborative construction project, it will take effort, communication, and understanding to achieve success. 

Sean M. Mulholland, PE, CHC, is director of planning, design and construction at Children’s Hospital Colorado, Aurora, and Caroline M. Clevenger, PE, Ph.D. is associate professor and assistant director of construction engineering and management at the University of Colorado Denver's college of engineering, design and computing. They can be reached at Sean.Mulholland@childrenscolorado.org and caroline.clevenger@ucdenver.edu.