The delivery method defines who holds which contract, when each party is engaged, and how design and construction responsibility are split. For acute-care hospitals the choice is driven less by first cost than by schedule certainty, owner risk tolerance, the complexity of mechanical/electrical/plumbing (MEP) and low-voltage systems, and the level of clinical-user involvement required to get rooms right.

Design-Bid-Build (DBB)

The owner contracts separately and sequentially with a designer (A/E) and, after construction documents are complete, a low-bid general contractor.

• Strengths: price transparency; often mandated for public/state-funded hospitals.
• Weaknesses (acute in healthcare): no constructor input during design, so constructability and long-lead procurement (air handlers, chillers, generators, medical-gas systems, imaging infrastructure) surface late; the linear schedule is the slowest; and the adversarial change-order posture is poorly suited to the volume of clinically driven revisions hospitals generate.

Use DBB for straightforward, well-defined scopes or where statute requires it — and pair it with rigorous design completion before bid to avoid bid-day surprises.

CM at Risk (CMAR / CM/GC)

The owner engages a construction manager early under a preconstruction services agreement, then converts to a Guaranteed Maximum Price (GMP) as design matures (commonly at 60–90% design development). This is the dominant model for complex acute-care hospitals.

The CM provides constructability review, real-time estimating, long-lead procurement, open-book trade-package bidding, and phasing logic for occupied-facility work. The GMP caps owner exposure while preserving competitive subcontractor bidding.

Watch the GMP timing. Locking too early on incomplete design transfers excessive contingency to the owner via inflated buyout; locking too late forfeits cost certainty. Negotiate clear definitions of CM contingency vs. owner contingency, shared-savings terms, and allowance reconciliation.

Design-Build (DB) and Progressive DB

A single entity holds both design and construction responsibility under one contract, accelerating schedule through overlap (fast-track) and giving the owner a single point of accountability. DB shifts design risk to the builder — powerful for speed, but it can pressure clinical quality if the owner does not retain strong design oversight.

Mitigate with:

• a robust owner's program/criteria document;
• bridging documents — an owner-side A/E develops design to ~30% to lock clinical intent before handing to the DB team;
• an owner's representative / commissioning authority who protects FGI Guidelines compliance, room-by-room clinical adjacencies, and infrastructure capacity.

Progressive Design-Build — a two-phase DB where the team is selected on qualifications and price is set collaboratively via an open-book GMP — blends DB speed with CMAR-style transparency and is increasingly favored for hospitals.

Integrated Project Delivery (IPD)

A multi-party relational contract binds owner, A/E, and CM/builder (and sometimes key trades such as mechanical and electrical) into shared risk/reward: a collective profit pool tied to validated targets, mutual liability waivers among parties, and collaborative decision-making via a project management team and senior management team.

IPD shines on large, complex, schedule-critical hospital programs where target value design (TVD), co-location ("big rooms"), and BIM-based coordination of dense MEP, medical-gas, and low-voltage systems pay off. It demands a sophisticated, committed owner and mature partners; it is poorly suited to small renovations or organizations unable to staff continuous involvement.