From Capital Planning to First Patient: Permitting Healthcare Growth in Texas
By Helen Callier
September 1st, 2026
As I am writing this article while listening to the early morning birds singing, I am reflecting on panel comments shared during recent transportation industry luncheons. Stats like 1000 people a day are still relocating to Texas were mentioned.
And that many of those are moving into the Texas Triangle – Houston to DFW to Austin to San Antonio area – where there are available jobs, low cost of living, good schools, safe neighborhoods, nice restaurants, nearby grocery stores and close healthcare (hospitals, clinics, pharmacies, etc.).
With this population growth in the Texas Triangle, demands (for service, on systems, staff, etc.) have increased on hospitals and clinics that were designed originally to serve smaller populations.
And when you consider the following social factors:
- more than 11,000 Baby Boomers reach retirement age each day, some with aging related ailments,
- healthcare deserts,
- affordability of medical insurance premiums,
…you’ll then realize that the availability of some hospital services is out of balance with original planned demand and infrastructure.
And who takes notice of this healthcare market opportunity?
Private capital does and begins to invest hundreds of millions of dollars in hospital expansions, new hospitals, clinics, lab renovations, etc.
And public hospital owners, with aged facilities and challenges in handling current patient loads, start feasibility studies and explore funding options for improving healthcare facilities.
When hospital executives, boards, and private investors are rounding-the-corner on funding options and possible development strategies, most jurisdictions have been left out of the early discussions. And when new large or complex hospital projects enter the permitting realm, plan reviewers are often pressed and stretched to perform plan reviews quickly.
And we are seeing these healthcare investments in Houston and across Texas.
For example, Memorial Hermann is underway with a $277.5 million expansion of its Cypress hospital. In North Texas, Texas Health Southwest Fort Worth announced a $223 million expansion, including a new patient tower. And on the public side, Harris Health is well underway with its multi-billion-dollar facilities expansion program, including the new John M. O’Quinn Hospital and future Ben Taub improvements.
All of this capital for healthcare facilities eventually reaches the permitting and regulatory gates.
Owners typically bring financial, design, construction and operational expertise into healthcare feasibility studies. Regulatory expertise and the AHJs that ultimately have to approve the project need a seat at the table early too.
And below in Table 1 are five suggestions on engaging AHJs early for a successful project start and delivery.
Table 1
| Permitting / Regulatory Tip | Why It Matters |
|---|---|
| 1. Bring AHJs into the feasibility stage. | Meet with key regulatory agencies while the owner is still evaluating the project. Identify potential showstoppers, changing regulations, code interpretations, infrastructure limitations, review capacity and upcoming ordinance/code changes before major project dollars are committed. |
| 2. Perform regulatory due diligence before solidifying the development strategy. | Determine the AHJs, approvals, agency dependencies, anticipated review times and unusual requirements that could affect the site, program, budget or hospital opening date. |
| 3. Build the permitting strategy around the construction strategy. | Determine early whether civil/site, foundations, central utility plant, core-and-shell, interiors and other packages can or should move separately—and obtain AHJ alignment before the design team builds its schedule around that assumption. |
| 4. Establish the regulatory critical path. | Map local building/fire approvals plus TDLR, healthcare regulatory requirements, utilities, civil/drainage and other applicable agencies against design, procurement and construction milestones. One approval sitting outside the CPM schedule can wreak havoc. |
| 5. Plan backward from first patient and not permit issuance. | The light at the end of the tunnel is TCO/CO and other approvals required to occupy and operate. Inspections, testing, fire/life-safety acceptance, accessibility and agency closeouts need to be thought about early and managed throughout construction. |
At the end of the day
It’s imperative to think and act differently as the objective isn’t simply to obtain a building permit. It is to move the project through permitting and the required regulatory gates so construction starts on time, stays on schedule and the new healthcare facility can reach TCO/CO to open and serve its first patient as planned.
For healthcare owners, developers and project teams: At what stage are you bringing permitting and regulatory strategy into your capital planning discussions?