Minimize disruption by sequencing a decant-first phasing plan, enforcing rigorous infection control barriers, coordinating early with authorities having jurisdiction (AHJ), and locking a guaranteed maximum price (GMP) that includes disruption clauses, all driven by patient-flow modeling and real-time operational dashboards.
Why it matters
In active hospitals, every hour of downtime has consequences: deferred procedures, strained staff, and risk to patient experience. Operating room closures can cost $6,000–$11,000 per room per hour in lost revenue and downstream throughput, according to AORN and MGMA-reported ranges. ASHE benchmarking shows that poorly planned phasing routinely adds 8–20% to schedule durations and 10–15% to project costs, primarily due to rework, shutdowns, and change orders. Protecting operations is therefore a core capital stewardship issue, not merely a construction concern.
Growth markets like Nashville and broader Middle Tennessee compound the challenge: high demand, tight labor, and busy inspectors create approval bottlenecks. AHJ review cycles commonly span 6–12 weeks for staged life-safety plans, and major imaging equipment lead times now run 26–52 weeks. Minimizing disruption requires aligning clinical schedules, supply-chain realities, and regulatory milestones into one integrated phasing roadmap.
How it works
Start with a decant strategy: temporarily relocate services from the work zone into swing space to keep clinical lanes open. For a typical 20,000–80,000 SF inpatient renovation, systems often use shell floors, modular clinics, or nearby ambulatory surgery centers (ASCs) to absorb volume; ASCs are outpatient surgical facilities that can offload elective cases during construction. Decant space typically costs $40–$80 per SF to ready, but it preserves higher-margin operations during a 9–24 month construction window. Use discrete phasing with sealed barriers, negative air, and HEPA filtration guided by ICRA (Infection Control Risk Assessment) classes to protect patients and staff.
Lock scope and schedule through an early GMP—guaranteed maximum price—set after design development, with explicit allowances for after-hours work and shutdown windows. Coordinate shutdowns using “hot work” and utility tie-in logs 4–8 weeks in advance, and align with AHJ (the code bodies and inspectors with approval authority) on interim life-safety measures. Pre-fabricate headwalls, MEP racks, and bathroom pods to reduce on-site duration; prefabrication can trim 10–20% of field labor time per RSMeans 2024 analyses. Sequence noisy or invasive tasks after hours and on weekends, and maintain a live operational risk register—tracking throughput, diversion incidents, and infection metrics—reviewed weekly by facilities, construction, and clinical leadership.
Key considerations
Budget and schedule: Hospital renovations range from $250–$600 per SF; imaging and ICU-level MEP intensity can reach $700–$900 per SF (RSMeans 2024). New bed towers and ED expansions commonly land between 60,000–150,000 SF and $600–$1,200 per SF depending on acuity and market. Phasing adds complexity: plan 10–15% cost contingency and 8–20% schedule contingency for live-hospital constraints, plus escalation assumptions of 4–6% annually for materials and labor. Secure long-lead equipment—MRI, CT, UPS, ATS, air handlers—early; OEM lead times of 26–52 weeks are typical in current supply conditions.
Operations and safety: Use ICRA to define barriers, differential pressure, and traffic patterns by phase, with daily logs validating air changes and particle counts. Protect egress by updating interim life safety measures and wayfinding each phase. Define “quiet hours” and “no-shutdown” windows with OR, ICU, and ED leaders; publish a rolling 6-week shutdown forecast tied to the master schedule. For Middle Tennessee sites, factor local noise ordinances, staff parking constraints, and known AHJ cycles in Davidson and surrounding counties to smooth inspections and occupancy sequencings.
Actionable takeaway
Stand up a disruption control center before design is 30% complete. This cross-functional team—operations, infection prevention, facilities, design-builder—owns the decant plan, phasing maps, shutdown calendar, and real-time KPIs (diversions, first-case on-time starts, HCAHPS noise scores). Write disruption protections into the GMP: unit-rate premiums for after-hours work, liquidated damages tied to missed shutdown windows, and allowances for temporary partitions, negative air, and wayfinding refreshes. As outlined in our healthcare real estate services, aligning capital strategy with clinical throughput from day one prevents costly midstream changes.
Practical tip: Pilot your plan in one unit for two weeks before full rollout—simulate barriers, test noise and vibration thresholds, and run a mock shutdown overnight with AHJ observers. This low-cost rehearsal (often under $25,000) surfaces sequencing conflicts early and builds clinical confidence. For leaders seeking a quick diagnostic, schedule a 60-minute phasing audit and preliminary decant sketch using your current floor plans and 12 months of throughput data, as seen in our advisory approach. If you need a facilitated session with your clinical and facilities leaders, reach out through our consultation page.
healthcare real estate services
What is the role of AHJ during a phased hospital expansion?
The authority having jurisdiction (AHJ) reviews and approves life safety, infection control, and occupancy sequencing for each phase, including interim egress, fire alarm impairments, and barrier strategies. Expect 6–12 weeks for staged approvals, plus inspection time before each area reopens; early coordination with fire marshals and building officials reduces rework.
How much does phasing typically add to cost and schedule?
Industry data from ASHE and RSMeans indicate phasing premiums of 10–15% in cost and 8–20% in duration, driven by after-hours work, temporary utilities, barriers, and resequencing. Projects with heavy MEP tie-ins or imaging replacements trend to the higher end, especially when long-lead equipment creates idle periods unless pre-planned with enabling work.
When should we lock a GMP, and what should it include?
A GMP is best set at the end of design development when scopes are defined but before major procurement, typically 12–20 weeks into design. Include allowances for negative air, temporary partitions, after-hours premiums, shutdown contingencies, and escalation, plus clear liquidated damages and incentives tied to clinical uptime metrics.
How do we keep patient and staff safety paramount during construction?
Use ICRA to set class-based controls, monitor air quality daily, maintain negative pressure in construction zones, and separate patient routes from construction routes. Update interim life safety plans each phase, conduct weekly safety walks with infection prevention and nursing, and keep an incident command structure ready for any unplanned utility event.
Is decanting to an ASC worth it for surgical programs?
For systems with elective case volume, temporarily shifting to an ASC can preserve high-margin throughput during OR renovations; ASCs are outpatient surgical centers optimized for predictable cases. Even after accounting for $40–$80 per SF in swing-space readiness and staffing adjustments, the avoided revenue loss from OR downtime over 6–12 months often justifies the decant, especially in competitive markets like Nashville.
Bremner Healthcare Real Estate partners with health systems to align real estate strategy with clinical performance and capital efficiency.