The pattern that repeats

Here is the scenario Pereff sees on repeat. A doctor decides to build. They hire an architect, wait four to six months for construction documents, then send the drawings to three GCs for bids. The bids come back. One is low. They pick the low bid. Six months into construction, the change orders start. By the time they get their Certificate of Occupancy, the 'low bid' is the highest number on the table.

The mistake wasn't picking the low bidder. The mistake was designing the project without a builder in the room — and then shopping the result after the most important cost decisions were already locked in.

What are holes and busts?

These are two distinct categories of design error that become change orders in design-bid-build delivery:

• Holes: things missing from the plans entirely. A drain that needs to exist but wasn't drawn. A conduit left off the electrical sheet. A shielded wall not specified in the radiation report. Each one is a hole — something that has to be built, wasn't bid, and becomes a change order.
• Busts: things drawn but designed wrong. An operatory width that doesn't fit the chair and dental unit. A plumbing rough-in that conflicts with the existing slab. An HVAC unit specified at 3-ton when the air-change requirements need 5-ton. Each bust requires a design revision, a construction revision, and usually a change order.

Why design-bid-build creates adversarial relationships

In design-bid-build, the architect and the general contractor have separate contracts with the owner. They are not on the same team — they are two separate vendors with different economic incentives:

• The architect's fee is paid. Their incentive is to defend their drawings and avoid redesign fees. When a hole or bust appears in the field, the architect's default position is 'the contractor should have caught that in the bid.'
• The contractor's margin depends on change orders. Their incentive is to identify everything the architect didn't specify and price each one as extra work. When a hole appears, the contractor's default position is 'this isn't in our scope — here's a change order.'
• The doctor has no leverage. Both parties are technically correct under their respective contracts. The owner pays the change order or pays a lawyer. Often both.

The 60–80% cost lock principle

There is a well-documented principle in project delivery: the decisions made in the first 15–20% of a project's design phase — programming, schematic design, and design development — lock in 60–80% of the final project cost. By the time an architect hands over construction documents, most cost decisions have already been made.

If a builder isn't in the room during those phases, the design is developed against aesthetic and functional goals — not against a real budget. By the time the bid documents go out, the structural system is chosen, the MEP concept is set, the finish level is specified. A GC reading the drawings can identify value engineering opportunities, but many of the high-cost decisions are already load-bearing — changing them means revising drawings, which costs time and fees.

What true design-build changes

True design-build isn't just combining architecture and construction under one contract. The real value is that it changes when cost decisions get made and by whom.

• Budget validation at schematic design, not at bid: In a design-build process, the GC runs cost models alongside the architect from the start. If the schematic design is 20% over budget, you know it in week four — not after 16 weeks of design and three rounds of bidding.
• MEP coordination happens at design development, not during construction: Plumbing conflicts with existing slab rough-in are identified when the architect is drawing — not when the plumber is standing on the slab.
• The bank's loan pro forma is created during the construction document phase: Scope is built to a real budget target. If it's heading over budget, it gets value-engineered out before the doctor has signed a construction contract.
• The contractor reviews every design sheet before it goes to permit: Not as a check — as a co-author. If something can't be built as drawn, it gets fixed in the drawing.
• Fewer disputes, because there's one team: In design-bid-build, the gap between what the architect specified and what the contractor bid is frequently the source of claims. In design-build, there's no gap — the designer and the builder are the same team.

Real example: KVC Pediatric Dentistry

Dr. Velasquez and Dr. Chen needed a 3,000 SF pediatric dental office at a specific bank-approved budget. Their previous dental consultant had failed to deliver a competitive architect or builder — the project was stalling. Pereff replaced the consulting firm, completed the design and construction together, and delivered the project at $423,000 — value-engineered to meet the bank's approved budget. No change orders from holes or busts. The project was complete in 3 months from groundbreaking.

When design-bid-build still makes sense

Design-bid-build remains the right choice in specific situations. Pereff will recommend it honestly when it fits:

• The design is fully complete, code-compliant, and the scope is clearly defined — there are few holes left to find.
• The owner has time flexibility and wants to run a competitive bid process to establish market pricing.
• A specialized architect who does not work in a design-build structure has already been engaged and the relationship is valued.
• The project is publicly funded and competitive bidding is legally required.

For most first-time or time-sensitive healthcare owners in DFW, design-bid-build creates more risk than it removes. But there is no universal answer — the right delivery method depends on the specific project, the owner's situation, and the existing design state. Start with that 30-minute conversation before you pick a path.