How to choose a healthcare design firm

Choosing a design firm for a skilled nursing facility, assisted living community, or behavioral health project is a different exercise from choosing one for a hotel or an office. The environment you are buying has to pass survey, hold census, survive healthcare cleaning protocols, and get built — often around residents or patients who never leave the building. A beautiful portfolio is table stakes; what separates firms in this sector is fluency in the regulatory, operational, and procurement realities that healthcare imposes on every design decision.

This is the checklist we would use if we were on your side of the table. It is written for operators and owners evaluating firms for SNF, assisted living, memory care, and behavioral health work, and it is deliberately specific: the questions that expose weak fits, the red flags that predict painful projects, and the fee structures you will encounter. Use all of it, on us and on everyone else you interview.

Start with portfolio depth in your asset class

Healthcare is not one asset class. A firm with a strong hospital portfolio may have never carried a skilled nursing project through state licensure; a residential firm that has done one assisted living lobby has not confronted FGI requirements, resident-loaded egress, or the economics of a 120-bed building. Ask for completed projects in your specific asset class — not adjacent ones — and ask how many. Volume matters because pattern recognition matters: the firm on its twentieth skilled nursing building has already made and corrected the mistakes the firm on its second is about to make on your schedule.

Look for depth across the situations you will actually face: new construction and renovation, occupied buildings, unit refreshes and full repositionings. Our own skilled nursing facility design practice sits inside a healthcare portfolio of 27+ SNF and senior living projects across 21 states, and we would tell any operator to weigh that kind of repetition heavily — whoever it points to.

Test survey and licensure fluency directly

Design decisions in licensed care settings are regulatory decisions. Flooring transitions, corridor handrails, door hardware, furniture flame ratings, wall protection, delayed egress in memory care, ligature resistance in behavioral health — every one of these can surface as a survey finding if detailed wrong. Do not settle for a firm that says it “works closely with code consultants.” Ask direct questions and listen for direct answers: Which states have you carried projects through licensure in? Which FGI edition applies to this project type in this state? What have surveyors flagged on your past projects and what did you change?

The last question is the revealing one. Every experienced healthcare firm has survey stories; a firm with none either has not done the work or is not being straight with you. State-by-state variation is the other tell — licensing requirements differ enough between states that multi-state fluency has to be earned project by project, which is why we treat regulatory research as the first step of every engagement in a new jurisdiction.

Ask about occupied-renovation experience

Most senior care design work is renovation, and most renovation happens in occupied buildings. That demands a specific skill set: wing-by-wing phasing, infection control risk assessment, temporary dining plans, noise and dust windows scheduled around care routines, and construction documents that spell out the phasing rather than leaving it to the contractor to improvise. Ask a candidate firm to walk you through a completed occupied renovation — what the phasing plan looked like on paper, what broke, and how census held through construction. We wrote a full guide to renovating an occupied senior living facility that doubles as a list of what your design firm should already know.

Probe FF&E procurement discipline

Furniture is where healthcare projects quietly fail. Residential-grade product specified for a healthcare duty cycle fails in months; unmanaged procurement leaks budget through freight, damage, and substitutions; and a contractor-substituted “equal” chair with no moisture barrier becomes your problem, not theirs. Ask how the firm documents FF&E: item by item with manufacturer, model, finish, and upholstery, or as loose allowances? Ask who manages procurement, receiving, and installation, and who owns damage claims. Ask what happens when a specified item is discontinued mid-project — a firm with real procurement discipline has a substitution-approval process and can describe it without hesitating.

Judge documentation depth before you judge design

The difference between a design that photographs well and a project that builds well is documentation. Thin drawing sets produce change orders, contractor improvisation, and pricing that drifts from the day of award to the day of punch list. Ask to see a real construction documentation set from a comparable project — not a portfolio PDF. You are looking for finish plans and schedules, lighting and reflected ceiling plans, millwork details, wall protection details, and a complete FF&E specification, all coordinated. Every HH project closes with a Spec Book — drawings, finish schedules, and full FF&E documentation in one deliverable — because the contractor should price exactly what was designed, and so should the next contractor when you renovate the next building. Our process page shows where that documentation sits in the sequence from concept to installation.

If you operate a portfolio, ask about standards

Multi-facility operators have a problem single-building owners do not: consistency. A design standard — finishes, lighting, FF&E, and detailing that carry across buildings while flexing to each one — compresses design timelines, strengthens procurement pricing, and makes brand quality legible across a portfolio. Ask whether the firm has built and maintained design standards for a multi-facility operator, and how they handle the tension between the standard and each building’s constraints. We covered the mechanics in our guide to multi-facility healthcare design standards; a firm that has done this work will recognize every problem in it.

Reference questions worth asking

References are only as good as the questions. Skip the satisfaction questions and ask operational ones:

• Did the project pass survey without design-related findings? If there were findings, how did the firm respond?
• How close was the final construction cost to the budget the firm gave you at proposal stage?
• How many change orders traced back to gaps or conflicts in the design documents?
• If the building was occupied, did census hold through construction? What did residents and families complain about?
• Did the FF&E arrive as specified, on time, and who handled the damage and punch list?
• How did the firm behave when something went wrong — and something always goes wrong?
• Would you hire them for your next building without bidding it?

That last answer is the whole reference in one question.

Red flags

• A portfolio full of renderings and short on photographs of completed, occupied buildings.
• No completed projects in your asset class, explained away with “design is design.”
• Vagueness about which codes, FGI editions, or state licensing standards govern your project.
• A fee that is dramatically lower than every other proposal — the missing money reappears as thin documentation and change orders.
• No clear answer to who manages FF&E procurement, substitutions, and damage claims.
• No phasing plan — or a casual one — for an occupied building.
• Reluctance to share a full documentation set or put you in front of past healthcare clients.

Bring the firm in earlier than feels natural

The most common sequencing mistake we see is engaging the design firm after the budget is set and the architect’s plans are frozen. By then the decisions that drive both cost and census — dining venue count, unit mix, amenity program, memory care model — are already made, and the designer is decorating conclusions rather than shaping them. The better sequence brings interiors expertise into feasibility and programming: a firm that knows what a repositioning actually costs per square foot, which amenities move census in your market, and what surveyors will look at can save multiples of its fee before a single drawing is issued. If a candidate firm has nothing to offer at the pro forma stage, that tells you where their expertise ends.

Understand the fee structures you will see

Healthcare interior design fees typically arrive in one of three forms. Fixed fees tied to a defined scope are the most common and the easiest to compare — provided the scopes actually match, so read the exclusions first. Percentage-based fees tied to the interiors construction and FF&E value the firm documents commonly land in the mid single digits to low double digits depending on scope and project size. Hourly arrangements suit advisory work, pre-acquisition walkthroughs, and early feasibility. Whatever the structure, the comparison that matters is scope: does the fee include programming, space planning, full construction documentation, FF&E specification and procurement management, and construction-phase support with site visits — or does it stop at finish boards? A cheap fee for a thin scope is the most expensive option on the table; the money you save on design reappears multiplied in change orders and replacements.

How we fit this checklist

We wrote this list because it is the standard we hold ourselves to: 27+ skilled nursing and senior living projects, healthcare work across 21 states, 60M+ square feet designed, $2B in documentation, and a Spec Book at the end of every engagement. If you are evaluating firms for a SNF, assisted living, memory care, or behavioral health project, we are glad to be measured against every question above — and you should insist that everyone else you interview is too.