COMMON GOAL

An integrated project delivery contract and Lean design process drove the creation of MaineGeneral's new Alfond Center for Health, with team members sharing in risks and rewards to ensure its success By Jennifer Kovacs silvis

MaineGeneral Health is the amalgamation of a series of mergers over the years that's created a system of acute care hospitals, outpatient facilities, and home care services in Maine's Kennebec Valley. And when the time came for leadership to address two aging inpatient sites, its landscape was about to change again.

"We had more than $100 million in repairs that we needed to do to the buildings just to keep them updated but not improve anything for patients," says Chuck Hays, MaineGeneral president and CEO. "Ultimately, we decided that one new regional inpatient facility was the way to go and started that process."

The design team of SMRT Inc. (Portland. Maine) and TRO Jung Brannen (TROJB; Boston) was brought on board in 2009 through competitive bidding for the schematic design of a 192-bed, $322 million hospital proposed in MaineGeneral's certificate of need to the state.

However, when the project got the green light, Hays was looking at the largest construction project in the system's history as well as in his own career, so he wanted to make sure it was done right. Research of similar-sized projects and their delivery methods zeroed in on what would be another first for Hays: an integrated project delivery (IPD) contract. "I liked the tenets of it. I saw that when it was done right, the results are excellent. So we headed off in that direction," he says.

Team building

Getting from that point to the September 2013 completion of what today is the Alfond Center for Health in Augusta, Maine, meant covering a lot of new ground. To start, ownership had to select its IPD partners and come to terms on a contract.

A major component of IPD as a delivery method is early integration of all team members to streamline-and even overlap-design and construction, but signing a shared-risk contract is what makes it more than just a methodology. Contracts generally give partners equal stake in both risks and rewards so that all are similarly invested in meeting budget and schedule.

With SMRT and TROJB already on board, MaineGeneral needed a builder and subcontractors, but the process of choosing them was a bit different from the norm due to the inherently collaborative nature of IPD. with the attitude of potential team members weighed alongside skill and expertise. "Typically, you think about whether the contractors you select are physically able to do the job. Then you assess whether the bids are apples to apples. Then you realign all that and look at pricing. Now. though, whether best price or not, culture came first. If they didn't have the flexibility to embrace IPD, then it wouldn't work," Hays says.

Ultimately, a construction joint venture of Robins & Morton (Birmingham, Ala.) and HP Cummings (Portland, Maine) was chosen for the job with a number of major subcontractors and consultants also party to the IPD contract. However, because the process was still fairly new in 2010, exactly how risk would be shared was up in the air.

Rather than simply using a standard contract with a modification for IPD or other existing options, the group decided to craft its own, which led to its first team-building exercise. "We were fairly new to the construct and therefore invented it together," says Ellen Belknap, president of SMRT. "It was no joke putting that contract together from scratch, but the fact that we went through it and we all owned every verse, line, and chapter of it made a huge difference."

First steps included creating a memorandum of understanding that established the basic principles of the contract and gave each team member an equal seat at the IPD table. Next came lengthier discussions on specifics like insurance, with the parties agreeing to an owner-controlled umbrella policy requiring each member to waive liability in order to take part.

Under IPD, team members are charged with collaborating on solutions to problems that arise rather than pointing fingers and letting resolution fall to a single party. Hays admits there was some hesitancy about the approach-for example, could an architect really not be liable if it put the final stamp on drawings and an error caused a delay? "There was a lot of discussion around those pieces, but it worked better than I ever thought it would work," he says.

The contract negotiations ended up setting the tone for its years of execution, too. "Once you complete the contract, you really never look at it again, because you've got an attitude and you understand what that attitude is, and it's your job to teach others about that attitude moving forward," says Steve Evers, president of TROJB.

Lean forward

The decision to pursue IPD was born from MaineGeneral's desire to streamline its original 36-month schedule where possible, which heralded another big piece of the project: Lean. "IPD almost became an aspect of Lean that relates to the way you put up the building," Evers says. For example, when using IPD, the design and construction phases can overlap, meaning that once the building's footprint is determined, construction can progress even if the interiors aren't yet finalized.

Another Lean driver for the project was the use of préfabrication. With a delay in financing pushing the project start into late summer, the building's steel frame wasn't erected until winter, meaning the team needed a quick solution to sealing up the site before weather might impede progress, says Robert Gambrell, senior vice president of Robins & Morton. The answer was to prefabricate the building's exterior panels off-site for a quick installation.

That process was then applied to headwalls and bathroom pods for the patient rooms. In fact, those pieces were prefabricated on-site, with the team taking advantage of its expansive basement rather than renting warehouse space for the job.

Further supporting an easy préfabrication and installation of patient room elements was the decision to pursue a standardized design, an approach gleaned from numerous site visits the design team conducted of peer facilities. "It was so dramatic in terms of the duration of the labor in the field getting to the point of putting up drywall and painting. It was overnight in these units that had repeated elements, and it was due to prefab," Belknap says.

Other Lean approaches to interiors included reassessing traditional layouts-specifically those supporting the interventional platform of surgery, cardiac catheterization, endoscopy, angiography, and so on-and how they can be streamlined to reduce the duplication of staff and services. "Instead of having each of those modalities occurring in a silo," Belknap says, "we brought all of the interventional platforms together so any patient on a stretcher needing prep or recovery is in one of 64 treatment bays. It's a huge step in terms of efficiency for the hospital to embrace Lean for the delivery system."

MaineGeneral also opted for 36-bed inpatient units broken up into 12-bed pods with decentralized nurses' stations so that each pod is self-sustaining, meaning they can be opened or closed based on census, Hays notes.

Savings realized

The nature of an IPD contract allows flexibility in the constant assessment and re-assessment of a project, specifically when it comes to budget, For example, if a savings is realized, the team can figure out where that extra money might be reinvested to bring move value to the project.

Likewise, if a cost overrun arises, the team can meet to evaluate where another cost can be cut. It's those "mountains of doom," Evers quips, that brought all hands on deck to see where the budget could be tweaked to make things whole, assessing proposed cuts from a number of perspectives-from the patients' to the contractors'-to figure out what's best.

To keep track of budget, the team's collocation room (shared office space on-site) was equipped with a traffic light-type system that showed a red, yellow, or green signal to communicate where they were related to budget. "You'd know walking in that if the light was red, you didn't want to suggest things that would add to the budget. Everyone wanted those lights to go green," Belknap says. In the end, the team realized $20 million in savings from the original budget that was able to be put back into the project in the form of better mechanical systems and sustainable design elements (the project targeted LEED Silver and is trending toward LEED Gold).

Similarly, rather than designers turning over drawings that a construction team would then bring to life-the course a traditional design-bid-build project would take-IPD allows a constant collaboration to innovate what's on paper. Case in point: The design team came up with an idea to harvest rain water to use as greywater to flush the facility's toilets. When the design was turned over to a plumbing contractor, instead of the system simply being executed, the contractor pointed out that it required running twice as much piping than a traditional system and instead suggested using the harvested rain water as makeup water for the chiller, which required only a single pipe. "Here's this subcontractor who had a cost-savings idea that the design team wouldn't have thought of," Belknap says. "We would have lost that good idea [without IPD]. That's just one example of millions that happened every day."

The approach could be reversed, too, Gambrell says: "Contractors were in the design, but the design was in the construction." For example, the site was riddled with underground boulders the construction team was encountering when driving piles for the building's foundation. As a solution, the project engineer remained on-site every day during the process to be available to make immediate decisions on how to proceed rather than causing the team, and its pile driver subcontractor, to sit idle while waiting for a response.

As for schedule overall, the IPD approach allowed the team to pick up 10 months, reducing its expected 36-month timeline to 26 months, with just seven change orders.

"There's the saying you can die from a thousand razor blade cuts. I think you can heal by a thousand Band-Aids. It wasn't one thing that did it; it was every day someone came up with something that was great and works. You pick up pace, and it becomes weeks and months off the schedule," Gambrell says.

Keep it local

In addition to ownership requiring an integrated project delivery contract for MaineGeneral's new Alfond Center for Health in Augusta, Maine, there was also a strong desire to use local labor for the job in an area that was struggling economically.

To start, TRO Jung Brannen (TROJB; Boston) partnered with SMRT (Portland, Maine) for design, with Robins & Morton (Birmingham, Ala.) creating a construction joint venture with local firm HP Cummings (Portland, Maine).

However, when it was time to bring subcontractors on board, that challenge became a bit trickier, since Maine has a limited workforce with few contractors large enough to take on a project of this scale. In the end, though, 97 percent of contracts were written to Maine contractors and 90 percent of the 3,000 jobs created were filled by Maine residents-thanks, at times, to a little creativity.

For example, instead of finding a drywall contractor that could complete the entire 640,000-square-foot facility, the construction management joint venture worked with four local companies to help them create their own joint venture. "They broke up the job into small enough pieces for some of these contractors to each have different pieces. It worked out really well," says Chuck Hays, MaineGeneral president and CEO.

The process was a rewarding one for Robert Gambrell, senior vice president of Robins & Morton, who recognized his Alabama firm was coming into someone eise's home and wanted to award work to its host as much as possible. "For us, that was especially meaningful. When awarding these contracts to local people, you could see that that hadn't been done there before," he says.

Completion date: August 2013

Owner: MaineGeneral Health

Architecture: TRO Jung Brannen and SMRT

Interior design: TRO Jung Brannen and SMRT

Construction Manager Robins & Morton and HP Cummings. Joint Venture

Engineering: TRO Jung Brannen and SMRT

Total building area: 644.000 sq. ft.

Total construction cost: S312 million

Cost/sq. ft.: $485

Art/pictures: LFA Art Management LLC. Vox Photographs, Matt Hutton, Dan Marquis, Lauren Fensterstock

Carpet/flooring: Tandus, Mannington, Nora, Florim USA, Daltile, Stonehard

Ceiling/wall systems: Armstrong

Fabric/textiles: LDI, Arc Com. Knoll, Pallas, Designtex, Bernhardt, Mayer, Maharam. Momentum, Architex

Furniture-seating/casegoods: Carolina, Kl. HBF, Knoll Studio, Weiiand, Nemschoff, Allsteel, Janus et Cie, Thomas Moser Contract, Standardmade, Spec

Handrails/wall guards: InPro Corp.

Lighting: David Pires/TROJB (lighting design), Mark Johnson/SMRT (landscape lighting design)

Slgnage/wayfinding: TROJB/SMRT

Surfaces-solid/othen Laminate. Wilsonart, Silestone

Wallcoverings: D.L. Couch, WallTalkers, Wolf Gordon

Glass: Skyline Design

Polyresin: 3-Form

Jennifer Kovacs Silvis is managing editor of Healthcare Design. She can be reached at jsilvis0vendomegrp.com.