The Construction Manager at Risk (CMAR) is a project delivery method tailored for complex hospital builds. It ensures early collaboration between the construction manager, architects, and engineers during the design phase, allowing for better cost control, scheduling, and constructability. The CMAR model sets a Guaranteed Maximum Price (GMP) - a financial ceiling where any cost overruns fall on the construction manager, not the hospital owner.
Key benefits of CMAR for hospital owners include:
This guide is designed for hospital owners and project leaders planning large-scale healthcare construction projects. It explains how CMAR works, its phases, and how to manage costs, risks, and schedules effectively. Additionally, it outlines critical roles like infection preventionists and BIM coordinators, ensuring compliance and safety during construction. By leveraging CMAR, hospitals can meet tight timelines while maintaining high standards for safety and functionality.
CMAR Project Phases for Hospital Construction: A Step-by-Step Overview
A CMAR contract revolves around three main components: preconstruction services, the Guaranteed Maximum Price (GMP), and construction services. These elements are designed to protect the owner's interests while keeping the project on track.
The GMP acts as the financial safeguard, ensuring that any costs exceeding the set limit come out of the Construction Manager's (CM) margin rather than the owner's budget. Jeff Benson, Principal at Benson Construction Group, explains:
"The CM is not earning more money by spending more money. The CM's fee is fixed... and cost overruns above the GMP come out of the CM's margin, not the owner's pocket."
Another critical aspect of these contracts is the separation of contingencies. The contractor contingency covers field adjustments and buyout variances, while the owner contingency handles elective scope changes or unforeseen external factors. This distinction helps clarify responsibilities and avoids disputes during construction. Additionally, most CMAR agreements include a shared savings provision, where any savings below the GMP are typically split 75% to the owner and 25% to the CMAR. This arrangement aligns both parties' financial goals.
| GMP Component | What It Covers |
|---|---|
| Trade Costs | Subcontractor work and materials |
| General Conditions | Overhead costs like site staff, temporary facilities, and insurance |
| CM Fee | Compensation for management and profit |
| Construction Contingency | Funds for scope gaps and field adjustments, managed by the CM |
| Owner Contingency | Funds for upgrades or scope changes, managed by the owner |
These contract elements form the foundation for the project phases outlined below.
With the contract framework in place, hospital construction projects progress through structured CMAR phases, which ensure cost control and adherence to timelines.
Preconstruction is where the CMAR model proves its worth. The CM works closely with the architect to provide early pricing, assess constructability, and map out the permitting process. This early collaboration minimizes the risk of costly redesigns. For perspective, large capital projects can exceed budgets by up to 80% and run 20% over schedule without this upfront alignment.
The GMP development phase begins once design documents are about 75–90% complete. Timing is key here - setting the GMP too early may lead to inflated contingencies to cover uncertainties, while waiting too long can reduce the benefits of early cost insights. Once finalized, the GMP becomes the financial benchmark for the project.
During Construction, the CM transitions into the role of general contractor, managing trade subcontracts and overseeing on-site operations. Open-book accounting ensures transparency throughout this phase. Finally, Commissioning and turnover focus on testing critical hospital systems like HVAC, medical gas, and electrical. This phase also includes staff training to guarantee smooth clinical operations from day one.
| CMAR Phase | Key Activities | Why It Matters |
|---|---|---|
| Preconstruction | Pricing, permit mapping, target value design | Prevents redesigns and stabilizes project scope |
| GMP Development | Finalizing cost cap and contingencies | Establishes financial accountability |
| Construction | Managing subcontracts and site safety | Keeps work within the GMP |
| Commissioning/Turnover | System testing and staff training | Ensures the facility is ready for clinical use |
For more on how CMAR stacks up against other construction models, check out this guide to construction project delivery.
With clear project phases established, defining roles becomes the next critical step in managing hospital CMAR projects.
The CMAR model uses separate contracts to ensure independent oversight. Each party - the owner, architect, and CM - has distinct responsibilities, creating checks and balances for both design quality and construction costs.
The hospital owner is responsible for defining the project scope, negotiating the GMP, reviewing trade bids, and managing the owner contingency. On larger projects, an Owner's Project Manager often handles daily decisions, while an Owner Stakeholder, such as a clinical operations lead, ensures the design supports hospital workflows.
The CMAR firm starts as a preconstruction advisor and later becomes the general contractor. Throughout the project, the CMAR employs open-book accounting, giving the owner full visibility into trade invoices, contingency use, and fee structures.
The architect ensures the design meets quality and safety standards while staying true to the project’s intent. Unlike design-build models, the architect in CMAR projects operates independently from the CM, which helps maintain design integrity and clinical safety. For large hospital projects, a Core Group - made up of representatives from the owner, architect, and CMAR - often oversees dispute resolution and monitors project health.
Hospital construction comes with strict rules around infection control, life safety, medical gas systems, and accreditation standards. The CMAR (Construction Manager at Risk) model tackles these challenges by embedding compliance into the process from the very beginning. During the preconstruction phase, the CMAR team collaborates with infection prevention staff, facilities managers, and clinical leadership to conduct an Infection Control Risk Assessment (ICRA). Using the ASHE ICRA matrix, the team assesses risks based on proximity to patient care areas and determines appropriate protective measures. This includes thorough planning, routine barrier inspections, and constant monitoring of negative air pressure to ensure compliance. All measures are carefully documented for accreditation purposes, and trade partners are trained specifically in infection control practices.
"Early ICRA planning is about more than compliance, but about respecting the clinical environment. By engaging infection prevention, facilities, and surgical teams early, we can plan construction around patient care, not the other way around." - Tyler Donnell, Project Executive, Barton Malow
With compliance under control, the next hurdle is ensuring hospital operations continue uninterrupted during construction.
A major challenge in hospital construction is working in an active facility where construction teams and patients might even share the same floor. To manage this, crews use full-height, airtight containment barriers with sealed penetrations and HEPA-filtered negative air machines to direct airflow back toward the construction zone. When permanent barriers aren't feasible - like during utility tie-ins in patient rooms - portable containment units are deployed to maintain infection control. For instance, during a renovation at Sheltering Arms Institute, Barton Malow handled utility tie-ins at 30 separate locations on an occupied floor. They set up individual containment measures in each patient room and sequenced the work to ensure patient safety.
"Hospital first, construction site second is a good rule to follow." - Rob Parr, Project Executive, The Christman Company
Clear communication between construction crews and clinical staff is essential for scheduling disruptive tasks around patient care.
In addition to ensuring safety and compliance, hospital construction involves managing highly intricate systems. Mechanical, electrical, and plumbing (MEP) systems alone can account for 35–40% of healthcare construction costs. Systems like medical gas piping, emergency power, nurse call systems, and imaging equipment require precise coordination. The CMAR model addresses this by involving specialty contractors early in the design phase, allowing teams to identify and resolve potential clashes before construction begins. Tools like Building Information Modeling (BIM) help visualize how these systems interact in three dimensions, making coordination more effective.
| System Type | Integration Challenge | CMAR Management Strategy |
|---|---|---|
| HVAC | Maintaining negative pressure and sterile environments | Sealed ducting and continuous digital pressure monitoring |
| Medical Equipment | High power and cooling demands for MRI, CT, and X-ray | Early coordination with equipment vendors during design |
| Medical Gas | Complex piping requiring certified specialty contractors | Early involvement of med-gas trades in BIM coordination |
| IT Infrastructure | Rapidly evolving hardware and high data demands | Oversized conduits and dedicated IT room expansion space |
Verifying actual site conditions is critical - relying solely on drawings can lead to costly mistakes. For example, a missed as-built line once resulted in a $200,000 error.
"Always double-check the as-built drawings. In one of our projects, we faced a situation where the line on the as-built drawing wasn't actually there. I drove a 360-degree camera in there to see the actual condition and found out it was missing. That cost us $200,000." - Dirk Schoenmaker, Project Manager, Halse-Martin Construction
Before diving into a CMAR project, hospital owners need to ensure they’re fully prepared - both financially and structurally. Start by establishing clear benchmarks for total project costs, expected completion timelines, and operational cash flow projections. This helps determine if CMAR can deliver the return on investment (ROI) you're aiming for. Keep in mind, large capital projects often run 20% longer than planned and up to 80% over budget.
It’s also critical to review your construction delivery options and define the project scope in detail. A poorly defined scope can weaken the Guaranteed Maximum Price (GMP) and lead to costly change orders later. Another key step is setting up a governance structure. This means identifying decision-makers for design-performance tradeoffs, outlining meeting schedules, and setting thresholds for change orders. These steps ensure alignment among hospital administrators, clinical leaders, and facilities teams . Proper preparation creates a solid foundation for selecting a qualified CMAR firm and managing potential risks effectively.
When selecting a CMAR firm, prioritize healthcare-specific experience. The unique challenges of hospital construction require expertise that goes beyond general commercial building projects.
| Selection Criteria | Why It Matters in Healthcare |
|---|---|
| Infection Control (ICRA) Training | Teams must know how to set up containment barriers and manage air filtration to protect sensitive environments. |
| Specialized Systems Experience | The firm should have experience with critical systems like medical gas piping, MRI/CT shielding, and negative pressure rooms. |
| BIM Proficiency | Building Information Modeling is essential for managing complex spaces and avoiding system clashes. |
| Local Market Knowledge | Familiarity with local permitting processes and Authority Having Jurisdiction (AHJ) timelines minimizes delays. |
| Subcontractor Vetting Process | The firm should thoroughly evaluate subcontractors for compliance with healthcare-specific safety standards. |
Before finalizing an agreement, ensure both parties align on how contingencies will be structured and managed. Breaking contingencies into categories - such as design development, permitting unknowns, and market escalations - provides a clearer understanding of where risks lie.
"CM at Risk supplies a Guaranteed Maximum Price tied to a defined scope, giving the owner cost protection while maintaining separate design responsibility." - Conseco Group
Once the right CMAR partner is on board, the focus shifts to actively managing costs, risks, and schedules.
Effective cost and schedule management in hospital CMAR projects starts with early collaboration. Engaging the CMAR firm early enables Target Value Design (TVD), which focuses on designing within budget limits from the outset. This proactive approach reduces the need for expensive redesigns and minimizes exposure to change orders.
When it comes to risk, the best strategy is to anticipate issues before they arise. As Chris Lucas, Director of Construction at Tampa General Hospital, explains:
"Addressing issues is simpler than identifying risks proactively. Ask: What risks haven't been anticipated?"
Time is money, especially in hospital construction. Accelerating a project can have significant financial benefits. For example, at a 4% annual cost inflation rate, completing a project six months early cuts cost exposure by about 2%. Even more importantly, opening a facility earlier allows clinical operations to begin sooner, generating revenue faster. Using Net Present Value (NPV) modeling can help quantify the financial impact of earlier facility openings, making a strong case for investing in detailed preconstruction planning.
A hospital CMAR project thrives on the expertise of a specialized team. Unlike commercial construction, healthcare projects demand professionals who excel in infection control, managing intricate systems, and working seamlessly within active patient care environments. These projects also require a deep understanding of the regulatory and operational complexities unique to hospitals.
One of the most critical team members is the Infection Preventionist. This role leads the Infection Control Risk Assessment (ICRA) process, identifying infection risks and implementing control measures aligned with CDC guidelines and Joint Commission standards. The stakes are high - Joint Commission citations for ICRA non-compliance can range from $15,000 to $50,000 per violation. Additionally, outbreaks of healthcare-associated infections linked to construction can extend a patient’s hospital stay by 4 to 6 days.
Another indispensable role is the MEP BIM Coordinator, who ensures that the hospital’s dense and interconnected systems - like HVAC, medical gas, electrical, and plumbing - are fully integrated. Resolving a single hard clash on-site can cost over $5,000 in labor and materials. By detecting these issues in the model at LOD 400, the coordinator minimizes on-site disruptions, supports prefabrication efforts, and reduces noise and dust in clinical areas.
| Role | Primary Responsibility | Key Regulatory Knowledge |
|---|---|---|
| Infection Preventionist | ICRA Matrix & Risk Mitigation | CDC Guidelines, Joint Commission PE Chapter |
| MEP BIM Coordinator | Clash Detection & System Integration | ASHRAE 170, NFPA 99, NEC Article 517 |
| Facility Engineer | Utility Continuity & HVAC Oversight | FGI Guidelines, Life Safety Codes |
| Project Manager | Schedule, Budget, and ICRA Protocols | ILSM (Interim Life Safety Measures) |
| EVS Director | Terminal Cleaning & Dust Control | Evidence-Based Cleaning Protocols |
The Facility Engineer ensures uninterrupted utility services and oversees HVAC operations within the constraints of an active hospital. Meanwhile, the Environmental Services (EVS) Director takes charge of contamination control and adjusts cleaning protocols to meet infection prevention standards during and after construction. Certified trade contractors, especially medical gas installers with NFPA 99 certification, are also vital for maintaining compliance and ensuring patient safety.
With these roles clearly defined, the next step is finding the right talent to fill them.
Once the key roles are identified, the focus shifts to recruiting the specialized talent required for hospital CMAR projects. It’s important to start the hiring process early - well before the contract is finalized. Data shows that hiring a construction leader typically takes 8 to 12 weeks, factoring in sourcing, interviews, notice periods, and onboarding. For example, if a project is scheduled to mobilize in September, searches for the Project Manager and Lead Superintendent should begin by February or March.
The hiring process should ideally occur in two phases. Leadership roles, such as the Project Executive, Project Manager, Lead Superintendent, and Preconstruction Lead, should be onboarded 4 to 6 months before mobilization. Supporting roles, including Assistant Project Managers, Safety Managers, and VDC/BIM staff, can join 2 to 3 months before the project starts. Delayed hiring can compress timelines and jeopardize critical preconstruction decisions.
Approximately 65% of U.S. healthcare construction projects involve work adjacent to active clinical zones. This makes experience in live facility renovations a must-have. Candidates with expertise in phased sequencing, managing large subcontractor teams, and maintaining strict infection control compliance in active hospital environments are particularly well-suited for these roles.
With a well-defined hiring strategy, the next step is to connect with candidates who meet these specialized requirements.
Finding candidates with the specific skills needed for hospital CMAR projects can be a challenge. That’s where iRecruit.co comes in. This platform specializes in mission-critical construction roles, including project managers, MEP specialists, scheduling leads, and field-level positions. Their screening process prioritizes technical expertise over generic qualifications, ensuring the right fit for complex healthcare projects.
For hospital owners, this approach offers clear benefits. A pre-qualified candidate pool saves time during critical hiring windows, while the success-based pricing model reduces financial risk. Additionally, iRecruit.co provides a 90-day search credit for replacements, offering peace of mind in case a hire doesn’t work out. In the high-stakes world of hospital CMAR projects, where leadership missteps can lead to compliance issues, cost overruns, and operational disruptions, assembling the right team from the start is crucial for success.
Once a CMAR project is completed, it’s crucial to assess outcomes to determine its overall success. In hospital construction, success goes beyond sticking to the schedule and budget - it involves meeting the unique demands of healthcare facilities.
One key metric is how well the Guaranteed Maximum Price (GMP) was managed. Owners should also monitor how contingency funds were used throughout the project. Linking these funds to specific milestones - like design completion, permitting, or structural close-out - helps clarify risk management and prevents unnecessary spending.
Schedule performance is another critical factor, especially in healthcare. Delays don’t just affect construction; they can push back the start of clinical operations, delaying revenue generation. To quantify the impact, hospital owners can calculate the monthly Net Operating Income (NOI) from clinical services and determine the financial cost of each week of delay - or the benefit of accelerating the schedule.
Compliance and risk management, which are central during earlier project phases, remain just as important during project closeout.
| KPI Category | Specific Metric | Purpose |
|---|---|---|
| Financial | GMP Adherence | Confirms cost control and budget certainty |
| Financial | Avoided Escalation | Measures savings from faster project completion |
| Operational | Clinical Revenue Timing | Evaluates the ROI of opening the facility earlier |
| Compliance | ICRA Certification Rate | Ensures safety in active patient care environments |
| Risk | Contingency Burn-down | Tracks how project uncertainty decreases over time |
On the compliance side, monitoring ICRA (Infection Control Risk Assessment) certification rates for the workforce and the pass rates for life safety system inspections is essential. Chris Lucas, Director of Construction at Tampa General Hospital, emphasizes the importance of proactive risk management:
"Fixing things that go wrong can be fairly straightforward. The harder part is identifying those risks before they happen. What have you not thought of yet? Where can you fail? Where are your biggest vulnerabilities?"
Once performance metrics are reviewed, the next step is consolidating these insights into actionable lessons.
In addition to tracking KPIs during the project, conducting a detailed post-project review is vital for improving future CMAR initiatives. This process sharpens budgeting, risk planning, and team coordination.
Start by comparing actual costs and completion dates with the original financial projections, like Net Present Value (NPV) and payback estimates. Then, conduct a contingency audit to analyze how funds were allocated across three main categories: design development, permitting and utility unknowns, and market escalation. This creates a historical reference that can guide future GMP negotiations.
Beyond financials, governance should also be reviewed. Were design decisions made efficiently? Did approval processes create delays? Documenting these factors helps refine roles and streamline decision-making for future projects. For hospital owners planning their next construction project delivery strategy, these structured debriefs separate successful one-off projects from consistently well-executed healthcare builds.
Lastly, compare the preconstruction risk register to what actually occurred on-site. If a flagged risk didn’t materialize, investigate why. If an unexpected issue arose, document it thoroughly. Over time, this process enhances risk identification, making future CMAR projects more predictable and manageable.
Hospitals should establish the Guaranteed Maximum Price (GMP) in a Construction Manager at Risk (CMAR) project during the pre-construction phase. This step should occur when the design is almost finalized, and both the owner and the construction manager have reached an agreement on the GMP. Setting the GMP at this stage helps ensure better cost predictability and alignment before construction kicks off.
Costs that might fluctuate under a Guaranteed Maximum Price (GMP) agreement include:
These adjustments often require revising the GMP to align with the updated scope or new conditions.
Construction in areas where patients are present requires extra care, and CMAR addresses this challenge by implementing strict infection control protocols. These include:
These steps are critical for keeping patient areas safe from potential contamination during construction activities.
