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The research problem in this study is how a client (as a project owner) should organise early stakeholder involvement and integration in the front-end phase of a project. This study aims to create normative managerial statements as propositions from the client's perspective and to combine them into a set of activities enabling efficient organisation in the front-end phase of a hospital construction project.

Action design research (ADR) was carried out in a large hospital construction project where the first author acted as an “involved researcher” and the other authors acted as “outside researchers”.

The authors created seven normative managerial propositions that were verified by the case project stakeholders and developed a managerial framework describing the client's essential stakeholder involvement and integration activities in the front-end phase of a hospital construction project based on these propositions. The authors have also depicted the subphases of the front-end phase: value definition phase in the client permanent organisation, value proposition phase in the client Programme Management Office (PMO) and finally development phase in the alliance organisation ending on the final investment decision.

The collaborative contract delivery model enables the early involvement and integration of stakeholders. It has been somewhat surprising to note the extent to which collaborative contracts change the client role in the project front-end. The results offer practical activities for how clients can manage front-end activities in collaborative contracts.

The case project offered a platform to analyse how the collaborative contract delivery model changes the emphasis of activities in the front-end of a project. One of the key benefits of collaborative contracts is that development, design and delivery occur partially in parallel, thereby enabling contributions from production to be included in the design and development. The benefit of having a real-life case under study provides the possibility to triangulate and analyse rich data, however limited by the qualitative case method.

The purpose of this paper is to present evidence to the heated debate “whether Public-Private Partnership (PPP) model should be introduced into the hospitals” and, if so, how to promote the social sustainability of such PPP projects.

This paper has established an analytical framework to analyse the social sustainability of PPP projects. Using content analysis method, a single case study was carried out on the Northern Beaches Hospital in Sydney, Australia.

The results show that there are many problems related to social sustainability in the project, due to which employees and patients were exposed to most of them. Some recommendations are provided, including to strengthen the supervision of the project, provide sufficient information, establish communication channels and stakeholder participation, improve hospital policies and procedures, and strengthen government support.

This paper can provide guidance for the stakeholders in a partnership, including the public and private sectors, to analyse the social sustainability implications, and then plan and implement hospital PPP projects to achieve social sustainability goals. Meanwhile, it can also provide important reference for the employees, patients, local community and society to assess social sustainability issues, and provide relevant inputs to inform decision-makers in the development, delivery and management of hospital projects.

The research will contribute to knowledge of social sustainability of hospital PPP projects. The proposed analytical framework can be used to analyse and assess the social sustainability of such projects from the perspective of stakeholders.

Hospital construction projects often suffer from relatively late changes in the project lifecycle, which disrupt the project execution and impact project productivity. The purpose of this paper is to explore the root causes of changes in hospital construction projects. The paper aims to propose ways to prepare for the changes.

The study focuses on changes during the construction of new hospital facilities. An explorative, case study research design is utilised. Five case projects from Finland, Sweden and the USA were selected for in-depth analysis. The primary data comprise semi-structured interviews, supported by secondary evidence such as change order documents.

The findings reveal eight categories for change sources: contracts, and equipment and systems are reflective of the fast-paced healthcare technology and changing user requirements, while external environment comprises changes caused by both regulatory and physical environment. Changes in operations are reflected in the continuous development of treatment methods and processes. The user, owner, designer and contractor initiated changes represent the stakeholder influence. The paper makes a connection between these change sources and project complexity dimension. A framework for change dynamics is introduced, and product and process flexibility is suggested as a suitable method to prepare for and manage changes.

The paper is the first to link construction changes to project complexity factors. The paper argues that changes, when managed appropriately, are not only necessary but also beneficial to large construction projects in a quickly changing environment. The findings guide project stakeholders in implementing project flexibility, in the product and process dimensions, which is a balancing force to project complexity.

Business process reengineering (BPR) is touted in the literature as the dramatic improvements necessary for competitiveness, but in practice there are many unsuccessful cases. A more systematic and rigorous factor-assessment deemed important to each BPR phase and overall project success is needed. This paper aims to assess the extent to which proposed success factors in a hospital contribute to each BPR phase's success.

Based on the relevant literature, desirable results from each project phase were defined. Overall project success was defined as the benefits hospital managers derive from BPR according to manager opinions. A total of 192 hospital administrators shared their last BPR experience, where changes were operational for at least one year.

Recommendations are made for hospital managers to focus attention and resources on factors important to BPR success. Hospital managers are not emphasizing the most important activities and tasks recommended in the BPR literature, such as changes to customer/market related business processes, every business activity's value-added element and applying the right innovative technology. Based on the whole findings, top managers should not engage BPR before ensuring that important success factors are present.

While many researchers identified and/or tested factors important to BPR success, this is the first study to explore BPR success factors' importance to each project phase, from inception to overall project success assessment phase.

The UK Government has now adopted Private Finance Initiative (PFI) as a major vehicle for the delivery of additional resources to the health sector in order to achieve a greater investment in healthcare facilities. The purpose of this paper is to examine the trends and risk assessment of the PFI in the healthcare sector.

The paper employed secondary data and interviews of key participants in two hospital PFI projects to highlight developments in healthcare PFI and the risk management of hospital projects.

The results show that the use of PFI in the provision of healthcare is increasing in terms of number, capital value and size of projects. What emerged in the healthcare PFI project was a usage of a plethora of risk management techniques, albeit to varying degrees. Experience appeared to be the prime risk assessment technique employed, while risk avoidance was first explored before pricing and allocating any residual risks. “Risk prompts”, such as using checklists and risk registers were also useful in the identification of risks. Among all participants, insurance cover and sub‐contracting appear to be the most prominent strategies employed for managing out the risks.

The negotiations that precede the signing of a healthcare PFI project contract had an impact on the final choice of facilities or their specifications. The two contracting parties sought a balance between an optimal allocation of risks, choice of facilities and project price. Although the risk management techniques being used are generic in nature, there is still no evidence at the moment to show that these are appropriate for PFI projects. It is important that further investigation is undertaken to assess the level of current skills in risk management techniques to deal with PFI projects and the extent to which these techniques are appropriate to tackle complex healthcare PFI projects.

This study primarily aims to analyse stakeholder management challenges and how these emerge in the stakeholder landscape in a large hospital project. From this analysis, the authors aim to identify the implications that stakeholder management has on value creation in a hospital project.

The research method is qualitative. Empirical data were collected in three cycles: project internal documentation, thematic interviews and survey. The literature related to hospital projects, stakeholder analysis and management, stakeholder salience and landscape is summarised, informing the qualitative design of the study.

The authors noted the importance of project-specific stakeholder identification, salience analysis and landscape description. The regulatory, formal and contractual stakeholders give an over-simplistic picture on stakeholder map. The operative stakeholder map and landscape describe the complexity, uncertainty, dynamism and institutional context inducing the challenges for the stakeholder management. There is an evident potential of utilising the stakeholder landscape and its elements in the resulting collaborative value creation in hospital projects. Multiple and changing stakeholders with differing expectations are an important opportunity to improve the value creation process.

Stakeholder management has recently attracted much attention in the industrial project setting. This research attempts to identify the operative stakeholder landscape in a large hospital project, not to mention its impact on value creation. This study offers a framework that can help academics and project management practitioners tackle the challenges amongst project stakeholders.

This paper aims to gain insight in how the involvement of facilities management (FM) and clinical employees are practiced in new Norwegian hospital projects and to study the benefits and lessons learned from the involvement.

This study is conducted by cross-sectional case studies of eight hospital projects by using a literature review, interviews and document studies of FM and clinical employees and project leaders (PLs) among Sykehusbygg.

The service design approach with a structured interaction between the PL’s of Sykehusbygg, and the different disciplines of clinical employees and FM specialist was rewarding and efficient. The facilitator role of Sykehusbygg is essential to manage such a broad and complex involvement process using a wide range of various techniques at the different stages of the projects (dialogue meetings, review meetings, workshops, post-it notes, 2-D drawings, mock-up and 3-D models, as well as virtual reality (VR) and Building Information Modeling technology). The clinical employees’ framework is stronger and much more structured than the involvement of FM competences through the different stages of the projects. The property management competences were involved at the early concept phase and design phase, whereas the Operation and Maintenance (O&M) competences were getting involved through the construction and commissioning phase. The value of FM involvement in all stages of the project is seen beneficial, particularly when the FM specialist become a part of the design team and located physically at the same place. The main reported benefits of early FM involvement are cost-effective technical solutions and installations, less design flaws and improved functionality, as well as a stronger ownership and mutual respect between the clinical and FM disciplines. However, not all hospital organizations see the benefits of the FM involvement of all stages, as they are driven by reducing capital cost. In one of the new projects, other ways of involving the FM competences were tested. Additionally, particularly for the O&M competences, a dialogue meeting with a clear focus of sharing experiences with different technical solution was found rewarding in terms of cost benefits.

This study does not consider the social impact of the choices made in the design phase. The findings also indicated a certain development of the FM involvement. This is not studied in two of the newest projects where they are still in the design phase and the FM role was not interviewed.

The PL role is important as a facilitator role of the involvement process.

A dialogue meeting with a group of O&M people was found rewarding and valuable for knowledge sharing. This methodology can be further developed and tested, as this group of stakeholders is not always available for giving input in the project.

The value of this study is the description of the interaction between the PLs and the hospital organization in the eight projects and lessons learned by the involvement of FM competences and clinical employees.

Social infrastructure projects such as hospitals are increasingly being procured through public private partnerships (PPP). Due to their complex nature and very high operational requirements, these healthcare projects need special attention in developing robust output specifications at the early procurement stage. The purpose of this paper is to present a model framework of output specifications for adoption by public sector clients in jurisdictions planning to develop hospital PPP/PFI (Private Finance Initiative) projects.

The research is based on an in-depth analysis of best practices from standard and sample project output specification documents used in Australia and the UK for completed hospital projects, reinforced by interviews with key stakeholders in the two countries.

Drafting output specifications for hospital PPP projects is perceived to be a difficult and challenging task due to the complexity and changing needs brought about by evolving health policy, technology and medical advancement. The overarching target of preparing good output specification is to achieve value for money, innovation, risk transfer (including catering for changes), whole life asset performance and establishing performance criteria to link up with the payment mechanism.

The proposed framework is built up from public sector requirements on the physical asset, operational services provided by the private sector, with links to payment mechanism and performance evaluation. It also addresses change mechanism as well as conditions upon hand-over back to the public sector.

Unlike traditional projects which are procured using prescriptive specifications, PPP/PFI projects are procured using performance based output specifications. This paper provides the foundation and a model framework for preparing comprehensive output specifications based on best practices in Australia and the UK, using hospital as the contextual background.

Hospitals in the developed countries have been subjected to increasing economic pressure. Thus, several hospitals have been forced to improve their production efficiency while coping with limited resources. This paper aims to illustrate challenges and insight associated with health care (HC) facility design (FD) in two publicly funded hospitals.

In this study, 14 interviewees from two Finnish university hospitals were interviewed. Both hospitals had implemented Lean methods and recently undergone rigorous renovation projects and were seen as ideal study targets.

Both hospitals had managed to carry out successful indoor environment design. However, logistics, navigation, health information technology, scheduling, budgeting and outsourcing challenges had arisen. An outpatient care approach and customer-driven operational needs are beneficial and guide FD in the target hospitals. Lean thinking offers the necessary fundamental framework for integrating operational design as a part of FD.

Due to the relatively small sample size of the interviewees in this study, post occupancy evaluations in a larger target group should be conducted in the present hospitals. Furthermore, the communication with the interviewees may be considered qualitative due to the research approach based on interviews and content analysis.

Hospital design should focus on developing aesthetic, durable and adaptable facilities that support work processes. The hospital management needs to ensure that architects and designers possess enough HC expertize and are able to interact with clinicians. FD projects should be led and organized more systematically, while project communication between all stakeholders should be more transparent and facilitated by – preferably – a hospital staff member. Furthermore, an organized forum for HC FD should be used for sharing knowledge. The clinicians must be thoroughly oriented to the new work environment and processes.

This paper brings forth numerous crucial challenges and insight related to management of FD in two university hospitals.

Evidence suggests that hospitals are having problems achieving continuous improvement project (CIP) goals or sustaining their results. Therefore, the purpose of this paper is to identify those critical success factors (CSFs) most strongly related to CIP success in hospitals (Lean-Kaizen project, Lean Six Sigma project, Six Sigma projects, and Quality Improvement projects).

A retrospective survey was applied to any CIP leaders/facilitators from hospitals that conducted at least one CIP during the last two years.

Three main findings were obtained from the 116 valid responses. First, the level of importance of 47 out of 53 CSFs to achieve CIPs success in hospitals was assessed as very important or higher (4 or higher on a six-point scale). Second, there are important differences between the CSFs to achieve CIP success in hospitals in this research and previous investigations. Third, the type of CIP affects the level of importance of 16 out of 53 CSFs to achieve CIP success in hospitals.

Practitioners involved with CIPs activities in hospitals could use the knowledge extracted from this investigation to improve the impact of their CIPs. Future research should continue in two lines: test if the 53 CSFs for CIPs measure a unique factor and identify the main relationships or paths between CSFs for CIPs and CIP outcomes.