Most founders I meet are trying to figure out who they need on a build before they know what the build actually involves. They've heard about brokers, architects, GCs. Someone mentioned a project manager. A friend told them about an owner's rep. They've usually never heard of a fractional VP of real estate, because there aren't many of us doing this work and the role doesn't get talked about the way the others do.
The question they're actually trying to answer is who shows up when, and who owns the work between the people they hire.
A first permanent clinic is a system. Each role does specialized work in a defined phase. The gaps between those phases are where the timeline and the budget end up — the couch cushion problem. The remote disappears into the seams, the loose change disappears with it, and nobody is paid to look for either one until someone notices they're gone.
Architects and GCs take most of the blame when projects run long or come in over budget. They shouldn't. The tightest projects I've run share one trait: the scope was clear before drawings started. The loose ones learned as they went. Every gap surfaced later as a change order, a redesign, or a delay.
What Each Phase Actually Asks Of You
The early-stage build, whether you're going 0→1 or moving from temp space into a permanent footprint, runs through four phases. Different specialists add the most value in different phases. Knowing when to bring them in matters as much as knowing who.
Who Shows Up When
Every other role engages in a phase and exits. Real estate leadership is the only role that carries across all four.
Phase 1 — Strategy and Lease
This is the highest-leverage phase, and the one most founders run with the least support.
There's a reason for that, and it's not naive. Most adults have looked for a building and signed a lease before. You did it when you bought a house or rented an apartment. The skills travel further than people give them credit for. You can read a market. You can negotiate. You can spot a bad landlord in a meeting. Founders who get to this phase are intelligent operators, and a lot of what happens here is within reach.
What changes in healthcare is what the lease has to absorb downstream. Every decision you make in this phase locks in constraints for the next eighteen months of construction and the next ten years of operations. The TI allowance has to fund a medical build, not an office build. The use clause has to permit clinical operations the city may classify differently than you expect. The landlord cooperation language is the difference between a permit getting signed in a week and rotting in someone's inbox for a month. The seasoned residential real estate brain doesn't catch these because they don't exist in the residential market.
You're defining the program. You're validating that the care model and the building agree with each other. You're testing zoning and permitting feasibility before you sign anything. And you're locking in lease economics that will either give you operational flexibility for ten years or take it away.
Broker. Sources space, runs market comps, brings landlord relationships. Your broker is (in the US) paid by the landlord. That doesn't make them adversarial, it makes them transactional. They can find you a building. They generally can't tell you whether the HVAC can carry your medical load, whether the use will permit, or whether the TI allowance reflects what your build actually costs.
Architect (light touch). A two-hour test fit before you sign saves you from leasing a space your program doesn't fit in. Worth it.
Real estate leadership. Someone has to read the LOI and the lease for the language that matters in healthcare. Landlord cooperation on permitting. Use exclusivity. TI economics that reflect medical build costs, not office build costs. Contingencies for regulatory delays. Some brokers know this work. Medical is a small slice of the overall commercial market, so the broker who's done dozens of healthcare deals is the exception, not the rule. And even the strong medical brokers usually haven't sat on the build side of a healthcare project. They know the market and they know how to push a landlord. They don't always know what a lease has to do to absorb what comes next. Real estate leadership bridges that gap.
Phase 2 — Design and Documentation
This is where most of the 25% budget and timeline overrun gets built in. Before anyone breaks ground.
You're hiring an architect. The architect brings in engineers — mechanical, electrical, plumbing, structural. Specialty consultants come in around them: lighting, acoustical, IT and low-voltage, interior design, sometimes medical equipment planning and audiovisual. Drawings progress through schematic design, design development, and construction documents.
How a 25% Overrun Gets Built In Before Anyone Breaks Ground
Step 1. Architect hired on base scope. Interior design isn't in it.
Step 2. Engineers scoped for code-minimum systems, not for medical IT or supplemental cooling. Each gap becomes a separate engagement.
Step 3. Specialty consultants added mid-stream. Architect revises drawings already produced.
Step 4. Package goes to bid with thin drawings. GC prices defensively. Every clarification becomes a change order.
Timeline +25%. Budget +25%.
Nobody did anything wrong. The scope was incomplete.
Here's the pattern I see often. A founder hires an architect on a base scope. Interior design isn't in it. Three months later it's a change order. The engineers are scoped for code-minimum systems, not for the medical-grade IT closet or the supplemental cooling for the procedure room. Each gap becomes a separate engagement, revising drawings the architect already produced, extending the timeline. By the time the package goes to bid, the contractor knows the drawings are thin and prices defensively. Every clarification after that becomes a change order.
Timeline up 25%. Budget up 25%. Nobody did anything wrong. The vendors executed what was in front of them. What was in front of them was an incomplete scope.
Architect. Owns the drawings and leads the design team. Strong architects ask hard questions about your operations early. Weak ones design what you describe and stop there.
Engineers (MEP, structural). Critical, and frequently under-scoped on the front end. Healthcare loads — power density, ventilation, water, data — are not commercial-office loads. The engineer needs to know that before design starts, not after.
Specialty consultants. Lighting, acoustical, IT and low-voltage, interior design, audiovisual, medical equipment planning. These can sit inside the architect's scope or be contracted directly. Decide which, before drawings start. Every consultant added mid-stream is a revision cycle.
Real estate leadership. Writes the architect's RFP so the scope is right before the contract is signed. Knows which engineering disciplines need to be brought in from day one and which consultants the architect will expect you to retain separately. Sits between you and the design team to keep budget conversations honest.
That last role is where I do the work my clients don't see. It's where the seat earns out.
Architects and GCs are routinely gun-shy about committing to numbers early. They've been burned before. You ask an architect for a budget range at schematic design. The architect hedges. You hear caution and gets nervous. The architect hedges harder. That spiral is why a lot of projects start with bad early budget signals that everyone then treats as gospel.
When I'm in the room with the founder and the architect, I make sure that spiral doesn't happen. The architect knows there's someone on the line who understands what stage we're at, what information is actually available, and what level of confidence we should reasonably expect at that point. They commit to a real range because they trust the range will be received as a range, not as a promise. The founder gets a number to plan against instead of a hedge wrapped in caveats.
The architect isn't being cautious with you. They're being cautious about the gap between what they know now and what the you will remember later. Close that gap with someone fluent in both languages, and the caution comes off.
Phase 3 — Permitting, Bidding, GC Selection
Permits are in plan check. Construction documents go out to bid. You're selecting a GC, negotiating the contract, and finalizing the construction budget.
Architect. Responds to plan-check comments, supports bid clarifications.
General contractor. The GC you want for a first healthcare build has done healthcare before and understands that early-stage projects evolve as they move through the city and through inspections. The cheapest bid is almost never the lowest total cost.
Real estate leadership. Running the bid process. Leveling proposals so you can actually compare them. Negotiating the contract. Pushing back on inflated contingencies and exposing thin ones. Setting expectations with the GC about how changes will be managed before the first change order shows up.
Phase 4 — Construction Through Activation
Construction is running. The city is inspecting. The vendors you under-prioritized during design — FF&E, medical equipment, IT, signage, security — are now on critical path. The clock to your Certificate of Occupancy is running.
GC. Building the project.
Architect and engineers. Construction administration, RFI responses, field changes.
Real estate leadership. Owning schedule. Owning budget. Owning change order discipline. Owning vendor sequencing into the building. Owning the handoff to operations. This is the phase where founders without real estate leadership find themselves spending twenty hours a week on project management they never budgeted for.
CofO isn't the finish line. The stretch between CofO and the first day of business is activation, where keys-in-hand becomes operationally ready. I've covered it in a separate post.
Where the Remote and the Loose Change Actually Go
Specialized vendors do specialized work inside defined scopes. The broker's scope ends at lease execution. The architect's scope ends with drawings and construction administration. The engineer's scope ends at the systems. The GC's scope ends at substantial completion.
The seams between those scopes are where the 25% lives.
Option 1
You Do It Yourself
The cost usually isn't a failed project. It's a delayed project, an over-budget project, and a founder who arrives at opening day already burned out.
Option 2
Delegate To Internal Team
Works in narrow circumstances. The translation dynamic that protects you from vendor hedging breaks when the person in the room doesn't speak the language.
Option 3
Full-Time Hire
Right answer at the wrong stage. A senior healthcare real estate operator costs $200K+ fully loaded. A first build doesn't generate a year of full-time senior work.
Option 4
Fractional Real Estate Leadership
Senior fluency, part-time, for nine to eighteen months. Heaviest engagement at the front of the project (strategy, lease, design scoping) and the back (construction oversight, activation).
Sized to the actual shape of the work — not a year of full-time cost for a project that doesn't need one.
