You Only Build Your First Clinic Once
Why first-time founders pay the most for the lessons they don’t learn early.
The First Clinic Teaches You Everything — But It Doesn’t Have to Be Expensive
First-time founders learn more in their first clinic buildout than they ever wanted to know about real estate development. I’ve sat beside founders through enough of these to know the emotional arc: excitement, frustration, surprise, exhaustion, and eventually, pride. My job is part advisor, part operator, and occasionally part therapist. The first project always creates a set of unforgettable memories—some you want to frame, some you want to forget—but all of them shape every clinic that comes after.
Every project has surprises, but the most expensive surprises are usually the result of skipped steps early on. The first clinic sets patterns (good and bad) that follow you into every future site. Costs, timelines, design decisions, workflow, and even your internal expectations all trace back to the choices made in that first version of the model.
Most of the painful lessons I see stem from the same upstream gap: not investing early in the expertise and clarity needed to build a clinic that reflects the care model, the brand, and the level of operational readiness the team believes they’re creating.
Where First-Time Founders Typically Stumble
Programming Assumptions That Don’t Match Reality
Many founders assume they already know what the space should look like—exam rooms, a nurses station, reception, maybe a few offices. A clinic is more than a collection of rooms. It’s an operational system, and every system depends on workflow, adjacencies, storage, and the right size and configuration of rooms.
Sufficient storage space trips up almost everyone. Early in one project, we assumed cabinetry would be enough for supplies and small equipment. It wasn’t. Larger equipment couldn’t fit, overflow storage ended up at the opposite end of the building, and staff spent unnecessary time walking back and forth.
The idea that “inventory will be lean and well-managed” rarely plays out in a new clinic. Staff are focused on keeping up with patients, not refining stock levels. Even the best-designed systems depend on adoption, and that adoption doesn’t happen in the chaos of opening year one.
Programming is certainly not a formality. It’s the work that aligns the care model with what the space actually needs to support day-to-day operations.
A Design Vision That Doesn’t Match What the Market Offers
Founders consistently value presence, visibility, and a modern patient experience. Those are the right priorities. But in major metro markets—especially after the post-COVID flight to quality—there are often hundreds of millions of square feet of commercial space and only a handful of buildings that can reasonably support a high-design healthcare environment without major investment.
I’ve worked with founders who budgeted $250 per square foot. Very reasonable on paper. Then we found the one building that could support the care model and patient experience, and it required $100–$200 per square foot in infrastructure upgrades and exterior improvements. Not because the team mismanaged anything, but because the initial assumptions about the market didn’t match reality.
You can create almost any environment with enough time and money. Most teams don’t have both. When the building doesn’t naturally support the vision, the budget absorbs the difference.
Misunderstanding the Actual Size of the Clinic
Another consistent issue is building a pro forma around usable square footage without accounting for rentable square footage. A founder may know they need roughly 6,000 usable square feet, but that can translate to 8,000 rentable square feet if you assume a 25% loss factor. That difference affects rent, layout constraints, staffing allocations, and even the number of revenue-generating rooms the space can actually support. Loss factor is the building’s way of allocating shared areas—corridors, lobbies, restrooms, mechanical rooms—into your rent. It’s not space you control, but you pay for it.
I’ve seen design teams rethink entire layouts, and even return to the market for new options, after realizing the gap between usable and rentable space. The programming was right, but the realities of usable vs. rentable square footage were not well-understood.
Your real estate broker may not flag this for you early. That’s when founders end up hunting for spaces that are too small for their program, leaving them with two choices: change the program, or start the search over.
Design and Standards Decisions That Don’t Exist Yet
Another pattern: founders who want a premium, patient-centered environment but haven’t documented their design intent, their brand standards, or even basic finishes and furniture selections before architectural work begins. Without that clarity, everything becomes reactive. Every design phase stretches longer than it should, and every change carries a cost.
I’ve seen founders hand over plans from an earlier project—sometimes even from a totally different market—and ask a design team to “create something like this.” It rarely works. Every building has different ceiling heights, different structural realities, different window placements, and different limitations. Without documented standards, the design team is forced to make assumptions, and those assumptions usually don’t match the founder’s expectations.
That’s when the redlines start: schematic design, DD, CDs, and then the change orders during construction. By that point, every correction is expensive. The founder may believe they’re saving money by skipping early design standard development, but they end up paying for the same decisions under pressure—when it costs the most.
Lease Language That Quietly Adds a Month to Your Schedule
Most founders focus on rent, term, and TI allowance. All important. But lease language also governs how fast your project can move. Some cities require landlords to sign off on permit applications before you can submit them. If the lease doesn’t set clear expectations—response times, approval criteria, and what “review” actually entails—your entire project can stall.
I’ve seen a landlord take weeks to sign a simple permit form because the lease didn’t obligate them to act within a defined timeframe. That delay cost the founder a full month in permitting. No one expects this going into their first project, but it’s a perfect example of how the first clinic exposes blind spots founders don’t even know they have.
Regulatory Surprises That Cascade Into Bigger Problems
Regulatory requirements are another place where first-time founders get caught off guard. Changing the use of a single suite can trigger building-wide upgrades. It’s especially common in retail and office. Cities may allow “existing conditions” on plan submissions, but that doesn’t mean inspectors will approve them.
One project stands out. An existing door swung out into the public right of way. Historically, that had been allowed. During construction, the inspector requested a minor adjustment to the pathway leading to the door. That change required modifying the door, and as soon as the door was part of the work scope, the inspector enforced current code: it could no longer swing into the right of way.
The fix? Rebuild the entire door system.
This is why a contingency budget is critical. A single adjustment in one part of the space can trigger unexpected compliance work elsewhere. Founders who haven’t been through a buildout before never see this coming. After their first experience, they never forget it.
The Staff Experience: The Thing No One Tells You About
There’s one nuance that rarely gets discussed, but it matters more than most founders expect: staff perception of fairness between locations.
If you upgrade something in clinic #2 that staff in clinic #1 interpret as “better,” you will hear about it. And you won’t hear about it once—you’ll hear about it repeatedly, from the same people, long after you’ve explained the reasoning.
I’ve seen this firsthand. A minor improvement—lighting, breakroom layout, a slightly different workflow pattern, a single card reader—can create a cascade of “Why don’t we have that?” conversations in your original clinic. Even when the answer is reasonable (the change wasn’t material, it would violate fire code, the building didn’t allow for it, the layout was different), some staff simply won’t accept it.
This is the cultural cost of building your prototype through improvisation. When clinic #1 and clinic #2 feel materially different in ways the staff interpret as unequal, you create unnecessary friction. Standardization matters as much for staff culture as it does for design.
The Moment Everything Changes: When You Treat Clinic #1 as the Prototype
Every founder figures this out eventually: the second clinic is always cheaper and faster—if you use the first clinic to build structure.
I worked with a founder whose first project was 20% over budget—well into seven figures. The issues weren’t unusual: incomplete programming, unclear adjacencies, undefined standards, and decisions made in real time because the model was still forming.
But during that process, we documented everything: the care model in practice, the real adjacencies, the space program that reflected operational realities, finishes and design intent, and a repeatable due diligence process.
Clinic #2 came in under budget. Not because we tried harder, but because the team had a documented prototype to work from. Instead of reinventing the model, they were refining it.
A Founder’s Framework for Building the First Clinic Well
Your first clinic will always be a learning experience. But the right guidance—and the right early decisions—turn that learning into an asset, not a liability. Here’s the framework I use with founders:
Start with the care model and workflow—not the room list. Programming shapes how care is delivered day to day.
Understand what the market can support before you set your budget. Your design vision has to match the buildings you can realistically secure.
Model rentable square footage, not just usable. Your pro forma lives or dies on this.
Establish design, brand, and furniture standards before plans are drawn. This is how you build a repeatable model—not a one-off clinic.
Let your contractor review the lease before you sign it. Lease language affects construction more than most founders realize.
Treat existing conditions as theoretical. Inspectors will define reality, not drawings.
7. Document everything. Your first clinic is a prototype. Your next clinics depend on what you capture now.
Final Reflection
You only build your first clinic once. It’s where your care model meets the real world—not the idealized version, but the version shaped by constraints, codes, market conditions, staff needs, and the thousand small decisions that make a clinic work.
When you invest in the right expertise early, you protect your budget, create a better patient and staff experience, and build the foundation for a model you can scale without reinventing it each time. When you don’t, the first clinic becomes the most expensive—and the lessons follow you into every new market.
You only get one prototype. Make it the one you want to replicate.
