Major capital projects rarely fail because of construction. They fail because of decisions made long before construction begins.
Project success or failure is often rooted in governance structures, decision-making processes, and organizational alignment before shovels break ground.
This article is the first in a series examining lessons learned while supporting a large academic health system through a complex capital program transition. The experience demonstrated that successful projects are often the result of disciplined executive decision-making long before the first contract is awarded.
A large academic healthcare system found itself managing a growing portfolio of major capital projects that had evolved independently over many years, each shaped by the priorities and habits of whoever happened to be sponsoring it at the time. The organization had capable planning, design, and construction professionals working on individual projects, but no consistent structure above the project level: no shared definition of what “ready to proceed” meant, no formal body with authority to weigh competing capital requests against each other, and no single point of executive accountability once a project was approved.
The result was a portfolio where projects entered design and procurement with wildly different degrees of business-case validation and operational readiness. Some had genuine executive sponsorship behind them from day one; others had accumulated momentum without anyone ever being asked to formally own the decision. Scope changes that should have surfaced during planning instead surfaced mid-design, when they were far more expensive to absorb. As capital costs rose and the portfolio grew more complex, leadership increasingly recognized that the projects running into trouble weren’t failing on site, they were failing at decision points that had never been clearly defined in the first place.
Recognizing that the underlying issues sat at the organizational level, Keel determined that better project management tools for individual projects wouldn’t solve a portfolio-level governance gap. The team approached the work not as a set of project rescues but as an organizational design problem: what structure would make it possible to evaluate every capital investment, large or small, early or late, against a consistent standard, with clear accountability for who was making which decision and when.
The centerpiece of the approach was a formal stage-gate framework spanning the full lifecycle of a capital project, from initial feasibility authorization through business case approval, construction and budget approval, construction completion, occupancy authorization, and financial close-out. Each gate carried its own defined criteria and required sign-off, so that a project couldn’t advance to design without a validated business case or advance to construction without a confirmed budget and schedule.
Alongside the stage-gate structure, Keel established a capital governance committee with defined executive ownership, chaired at the senior leadership level, with clear authority to resolve tradeoffs across the portfolio rather than leaving them to be negotiated project by project. A companion project sponsor model made explicit what had previously been implicit: every project needed a named executive sponsor accountable for the decisions at each gate, not just a project manager accountable for execution. Because not every capital request carries the same risk, the framework was tiered by project size and complexity, so a minor renovation and a major facility expansion moved through proportionate, not identical, levels of scrutiny.
Together, these elements reframed governance as the mechanism that made portfolio-level tradeoffs visible and executive accountability real.
Establishing capital governance as a formal, gated process produced measurable improvements across the portfolio. Projects that went through a Gate 0 feasibility review before entering planning saw far fewer scope changes surface mid-design, the kind of late-stage changes that used to add months and unbudgeted cost. Decisions that had previously stalled for weeks or months, with no clear owner to escalate to, now had a defined executive sponsor and a governance committee empowered to resolve them.
Just as importantly, leadership gained a shared vocabulary for capital decisions. A “Gate 2 approval” or “Tier 3 project” had common understandings across every service line. Portfolio-level tradeoffs, such as which projects to fund, delay, or resize, could be debated on consistent terms instead of ad hoc justification.
The clearest lesson from this work is that governance frameworks fail when they exist only on paper at the portfolio level, disconnected from accountability at the individual project level. A stage-gate structure without a named executive sponsor at each gate is just a checklist; a sponsorship model without portfolio-level governance just relocates the ownership problem instead of solving it. The two have to be built together.
By the time a project reaches construction, most of what determines its outcome has already been decided .
Who owns it, whether its business case was actually tested, and whether the organization agreed on what “ready” meant before design began. For complex capital programs, getting those decisions right is at least as consequential as the execution discipline applied on site.
