What Does a Fractional VP of Real Estate Do?
A fractional VP of real estate runs the real estate function for a healthcare operator on a part-time, retained basis. The role owns site strategy, lease negotiation, design direction, and build-out oversight through go-live, carrying the executive judgment a full-time VP would bring without the full-time cost. For a founder opening a first clinic or an operating partner scaling a portfolio, it puts experienced, full-time-caliber judgment on the highest-stakes line item before the mistakes get locked in.
I started Retained CRE because I kept watching the same gap open up. A founder has raised the round, signed the clinical hires, and is building a care model she believes in. Then real estate lands on their desk: a broker sending listings, an architect asking for a program, a landlord's LOI with seven terms that will shape the EBITDA for a decade. Nobody on the team has done this before, and the founder is the one improvising. The fractional VP of real estate exists to take that seat.
Key takeaways
- A fractional VP of real estate is a retained executive who runs the real estate function end to end: site strategy, lease, design, and build-out through stabilization.
- It is a different seat than a broker (paid on the transaction) or a consultant (advises and exits). The fractional VP stays through go-live and gives the founder the confidence that every phase has been managed with rigor.
- The clearest trigger is the first physical clinic, or the second site, where you find out whether you built a repeatable system or survived once on effort.
- Roughly 25% of a first-clinic timeline and budget disappears in the seams between brokers, architects, and contractors. The role's main job is to own those seams.
- You retain executive-level real estate judgment for a fraction of a full-time VP's loaded cost, which only pencils as a full hire once you are building several sites a year.
What does a fractional VP of real estate do day to day?
The work is the full real estate lifecycle, run by one person who is responsible for the execution rather than any single transaction. I think about it in four phases, and the value compounds across them because the decisions are connected. A site choice constrains the design. The design sets the build-out cost. The build-out schedule determines your opening date. When those phases are owned by four different vendors who each optimize their own slice, the seams between them are where the timeline and budget leak.
In my experience the leak is large and predictable. On a first clinic, somewhere around a quarter of the schedule and the budget vanishes in the handoffs: the program the architect drew that the contractor prices 30% over, the long-lead equipment nobody ordered until permits cleared, the inspection sequence that stalls because the wrong trade was on site first. A fractional VP of real estate is the person whose job is the handoffs, not the slices.
Site strategy
Define the ICP and trade area, choose the submarket, and run real estate decisions through the care model before anyone falls in love with a building. This is where I weigh second-generation medical space against a shell build, and where I kill sites that look right on a map and fail on access, co-tenancy, or power.
Lease and deal structure
Negotiate the LOI and lease as a financing instrument, not a monthly bill. The TI allowance, free-rent period, assignment rights, and exit mechanics decide how much capital the build consumes and what the location does to your enterprise value at exit. I have negotiated more than 200 leases, and the terms that matter are rarely the ones founders are watching.
Design direction
Translate the care model into a space program, select and manage the architect, and protect the decisions that drive throughput and staff retention. Put a lab or a check-in in the wrong place and you multiply that friction across every visit, every day, for the length of the lease.
Build-out and go-live
Select the general contractor on the strength of the team rather than the logo, coordinate the owner's project manager and vendors, manage the inspection-to-Certificate-of-Occupancy sequence, and run the handoff into operations. Construction being finished is not the same as being able to open.
That last phase is where I spend a lot of time, because it is the one founders underestimate most. I ran a PACE center build in downtown Los Angeles where the gap between substantial completion and an operational, licensed center was its own project. If you want the detail on why that phase is so fragile, we wrote it up in why construction being done does not mean you can open.
How is a fractional VP of real estate different from a broker or a consultant?
This is the question I get most, and the distinction matters because the incentives are different in each seat. A broker is paid a commission when a lease signs, which means the structural pull is toward a signed deal, not necessarily the right deal or the patience to walk away from a bad one. We wrote about where that model breaks in the broken brokerage model. A consultant advises, delivers a recommendation, and exits before the recommendation gets tested in a build. Neither is wrong for what it is. Neither one runs your real estate function.
Paid by transaction
Commission, usually landlord-funded. Scope ends at lease signing. Optimizes for closing the deal. Useful for market access and tour logistics. Does not own your design, your build, or your opening date.
Paid for advice
Paid for a deliverable. Scope ends at the recommendation. Optimizes for a defensible report. Useful for a discrete question. Is not in the room when the contractor reprices or the inspector fails the rough-in.
Retained to run it
Paid on retainer to run the function from site strategy through stabilization. Owns the execution at every seam so the decision reaching you is fully informed: on time, on budget, in a space that serves the care model.
The shorthand I use: a broker hands you options, a consultant hands you a recommendation, and a fractional VP runs the function so you can make the call with confidence. You live with the result, and you answer to your board. My job is to make sure that by the time a decision reaches you, every phase of the process, every dollar, and every inch of the facility has been paid attention to. When you retain me, I sit on your side of the table for every one of those handoffs, and I am the person watching the seams where the timeline and the budget leak.
When do you need a fractional VP of real estate?
There are two clear moments, and they map to the two readers of this piece.
For a founder, it is the first physical clinic. You have a care model that works and a team that has never signed a healthcare lease, drawn a clinical space program, or managed an inspector. The cost of learning on your first build is measured in months of runway and in lease terms you cannot undo for a decade. This is the seat I take most often, and you can read why I built the firm around it in why I started Retained CRE.
The second moment is the second site. Site two is where you find out whether you built a repeatable system or whether you survived site one on brute force. The work that one heroic founder did by hand the first time has to become a process the third, fifth, and tenth site can run on. A fractional VP of real estate is what turns a one-off into a playbook.
For a PE operating partner or an investor, the trigger is different but related. You have several portfolio companies expanding at once, and real estate is the line item with the most variance and the least in-house expertise. A full-time VP of real estate at each company is expensive and idle between projects. Retaining one fractional executive across the expansion gives you consistent underwriting, consistent execution, and one person who can tell you which sites are real and which are optimistic. The strategy is transferable across markets even when execution stays local.
What it costs, and what it protects
A full-time VP of real estate is a senior, loaded salary that only pencils once you are building several sites a year. A retained fractional executive gives you that judgment for a fraction of the cost, scaled to your actual pipeline.
Set against the downside, the math is straightforward: self-managed healthcare build-outs routinely run 25% to 50% over budget when the seams are unmanaged, and the cost of the role is small against the capital it protects. We made the full argument in capital protection versus coordination.
What a fractional VP of real estate does not do
The role is defined as much by its boundaries as its scope. I am precise about this because the value comes from running the function with rigor, not from collecting titles.
- It does not replace your broker, your architect, or your general contractor. It selects them, aligns them, and holds them to the plan.
- It does not run your clinical operations or your staffing. It builds the environment your operators run in.
- It is not a transactional, commission-driven seat. The whole point is to remove the conflict between getting paid and getting it right.
- It is not a one-time report. It is a standing function that stays through go-live and the first 90 days of stabilization.
The result: you get one experienced executive running the highest-stakes, lowest-familiarity part of your expansion, so you can make each call with confidence, without standing up a full department to get it.
The bottom line
A fractional VP of real estate is the answer to a specific problem: real estate is too consequential to improvise and too intermittent to staff full-time. The role puts executive judgment on site strategy, lease, design, and build-out into one seat that runs the function with rigor, priced to your pipeline rather than to a headcount.
For founders: if you are signing your first lease or planning your second site, the question is not whether you can manage the build yourself. It is whether you can afford the months and the locked-in terms that come from learning it live.
For operating partners and investors: one retained executive across your expanding portfolio gives you consistent underwriting and execution on the line item that carries the most variance, without a full-time hire at every company.
Have a site, a lease, or a build coming up?
Let's walk through where you are and what the next 90 days should look like. We'll cover:
- Whether your next site fits your care model and your capital plan
- The lease terms that protect EBITDA and exit value
- The realistic timeline from LOI to open
- Where the seams in your build are most likely to leak
Frequently asked questions
What is a fractional VP of real estate?
A fractional VP of real estate is a senior real estate executive retained part-time to run an organization's real estate function. In healthcare, that means running site strategy, lease negotiation, design direction, and build-out oversight through opening. You get executive judgment and the confidence that every phase has been managed, without the cost of a full-time hire.
How is a fractional VP of real estate different from a commercial broker?
A broker is paid a commission when a lease signs, so the incentive is to close a transaction. A fractional VP of real estate is retained to run the whole function and owns the execution from choosing the right site to opening the doors, so the founder can make each decision with confidence. The broker is one of several vendors the fractional VP selects and manages.
When should a healthcare founder hire a fractional VP of real estate?
The clearest moments are the first physical clinic and the second site. The first build is where founders lose months and lock in bad lease terms by learning on the job. The second site is where you find out whether your expansion is a repeatable system or a one-time effort that will not scale.
How much does a fractional VP of real estate cost?
It is structured as a retainer scaled to your pipeline, far below a full-time VP's loaded salary. The relevant comparison is the downside it prevents: self-managed healthcare build-outs commonly run 25% to 50% over budget, so the role is small against the capital and timeline it protects.
Can a fractional VP of real estate work across multiple sites or portfolio companies?
Yes. For PE operating partners and investors, one retained executive across an expanding portfolio delivers consistent underwriting and execution on the highest-variance line item, without a full-time real estate hire at each company. Strategy transfers across markets while execution stays local to each site.
