Transforming Healthcare at Scale: Five Pillars Inspired by Queensland’s Capacity Expansion Program

First Cut

Queensland Health’s Capacity Expansion Program (CEP) stands as one of the most significant health infrastructure initiatives in Australia’s history. With new hospitals, expanded services, and a multibillion-dollar investment, the program represents a committed response to growing demand across the state.

As the program progresses, a range of delivery challenges have surfaced — with budgets being revised, timelines extended, and expectations recalibrated. From these developments, several practical principles are becoming increasingly visible:

• Plan with discipline – Rigorous planning and well-developed business cases lay a stronger foundation.
• Govern with clarity – Transparent, empowered governance supports better decisions and surfacing of risk.
• Procure with realism – Aligning with market conditions helps secure value and contractor engagement.
• Engage meaningfully – Early involvement of clinicians and local leaders shapes more effective outcomes.
• Phase and adapt – Delivering in stages allows programs to respond to change and build momentum.

These reflections are shared with deep respect for the scale and ambition of the CEP. The aim is to support others navigating similarly complex digital and infrastructure transformations — not with hindsight, but with a spirit of partnership, shared learning, and practical insight.

Introduction

In 2022, Queensland launched the ambitious Capacity Expansion Program (CEP) to substantially increase hospital capacity. The $9.78 billion plan envisioned building three new hospitals, a new state-of-the-art cancer centre, and expansions at 11 existing facilities – adding 2,200 extra beds by 2028. As of 2025, the CEP’s budget has grown to a projected $17 billion, timelines have extended, and only a portion of the planned capacity is currently on track for timely delivery. An independent review found that, under the original plan, none of the projects were deliverable by 2028, with major components such as the Queensland Cancer Centre now forecast for completion in 2031.

Rather than viewing this as a cautionary tale, we see the CEP as a valuable source of shared learning for the broader health sector. The program’s evolution provides rich insights into the realities of executing complex transformation at scale. Whether expanding physical infrastructure or implementing a new digital health platform, the fundamental challenges of planning, governance, stakeholder alignment, and execution are strikingly similar. In this article, we take an inquisitive look at the CEP as a case study in large-scale health transformation, identifying five key pillars that have emerged as critical for success. Each pillar is illustrated with specific examples from the CEP’s experience and translated into practical guidance for digital health executives, CIOs, public health department leaders, and other stakeholders. The goal is to foster actionable insights that can help de-risk and accelerate digital health initiatives, in a spirit of collective improvement.

The Five Pillars of Digital Health Transformation

Drawing inspiration from the CEP experience, we suggest a five-pillar framework for successful digital health transformation programs. In summary, the pillars are:

• Rigorous Planning and Business Case Discipline – Invest upfront time in thorough planning and evidence-based business cases to avoid downstream surprises.
• Strong Governance and Accountability – Establish transparent, accountable program governance that balances ambition with realism and actively manages risks.
• Market-Aligned Procurement and Budgeting – Align project scope and contracts with market realities (costs, capacity, supply chain) to ensure feasibility and value for money.
• Stakeholder Engagement and Clinical Co-Design – Involve frontline clinicians and local leaders early to shape solutions that meet real needs and secure broad buy-in.
• Phased Implementation and Adaptive Execution – Break down big-bang projects into phased deliverables, allowing flexibility to adjust plans as conditions change.

Each pillar is explored in depth below, with a focus on how the CEP journey highlights its importance and how digital health programs might apply these learnings. The intent is to offer both analytical depth and practical relevance, supporting decision-makers as they navigate their own transformation challenges.

Pillar 1: Rigorous Planning and Business Case Discipline

Major transformation starts with thoughtful planning. A recurring theme in the CEP review was the challenge of condensed planning timelines, which sometimes led to normal due diligence steps being compressed. For example, the 15 hospital projects in the CEP were scoped in around six weeks in 2022 – a notably short timeframe for such complex health infrastructure planning. This accelerated cycle appears to have contributed to some critical details being missed. Subsequent cost increases were partly attributed to scope elements that had been overlooked or underestimated due to the rapid pace – for example, additional “support services” infrastructure, complex site conditions, and necessary utility upgrades that weren’t fully accounted for in initial budgets. In the digital realm, this could be analogous to underestimating integration complexity or neglecting technical debt in a new EHR (Electronic Health Record) rollout: if all requirements and constraints aren’t mapped out up front, reality can catch up later in the form of delays and added expenses.

Additionally, the CEP moved forward before completing full business cases prior to government approval of projects. The independent review noted that formal business cases were still under development after the political announcement of the program. In this context, the significant funding commitment was made before the usual rigorous validation of costs, benefits, and risks. While such decisions are often driven by urgent needs and complex pressures, the CEP’s experience suggests that skipping or abbreviating the business case process can create challenges down the track — with inevitable scope changes and budget increases emerging because initial cost estimates were not yet grounded in detailed analysis. For example, when tenders came in for some hospital expansions in late 2024, budgets needed to be increased by over 70% just to award the contracts into construction, highlighting the need for robust early planning.

For digital health leaders, the CEP experience invites us to reflect on the value of comprehensive upfront planning. No matter how urgent the pressures, investing time in thorough planning and business case development seems vital for large initiatives. This means assembling capable planning teams, conducting thorough needs assessments, validating assumptions with data, and realistically estimating costs and timelines. Best practices like stage-gated business cases (preliminary vs. detailed) and independent quality reviews (e.g. gateway reviews) can help ensure that, by the time a project is approved, its scope and strategy have been pressure-tested. Rushing through this phase may provide short-term momentum, but as the CEP journey suggests, it can increase the risk of longer-term challenges. For instance, in Bundaberg, site works for a new hospital began enthusiastically in 2022, only to be paused when it became clear that funding was insufficient and key issues hadn’t been resolved. Strong planning discipline might have identified such issues in advance, reducing the risk of wasted effort and uncertainty.

In summary, “measure twice, cut once” applies to digital health transformations as much as construction projects. Grounding every major decision in a solid business case and a realistic project plan can help anticipate and mitigate downstream surprises. The CEP’s experience, viewed with humility and curiosity, offers valuable reminders about the importance of disciplined planning in large-scale transformation.

Pillar 2: Strong Governance and Accountability

Even the best-laid plans benefit from effective governance. The CEP experience highlights the importance of transparent and empowered oversight structures that balance ambition with operational reality. The independent review observed that the program “was governed in a manner where project timelines dominated… but this approach was futile.” In practice, this meant a strong focus on the 2028 deadline, which sometimes led teams to prioritize schedule over flexibility — even as warning signs emerged about the achievability of the timeline. Internal and external experts reportedly raised concerns (for instance, about construction market constraints and budget estimates), yet these warnings were not always fully acted upon in governance forums. The decision-making culture appeared to value optimistic reporting over candid risk escalation, and as a result, early opportunities to adjust scope or timelines may have been missed, with problems surfacing only when they became impossible to ignore.

Transparency in program oversight is another area where the CEP offers valuable lessons. In some cases, key financial information was not always shared with those responsible for governance. The review found instances where project financial data was redacted or withheld from steering committees under the pretext of “commercial in confidence”, even though those committees were composed of senior government executives with a clear stake in the outcomes. Such opacity can erode trust and limit the ability of governance bodies to course-correct. For example, Queensland’s hospital CEOs began to perceive a “black box” at the center of the program — a disconnect between the Health Infrastructure agency running CEP and the local health services who would ultimately operate the facilities. When governance lacks openness, it can breed skepticism among stakeholders and diminish accountability.

For digital health initiatives, this invites us to consider governance structures that are transparent, expert-informed, and open to confronting reality. This starts with clarifying roles and decision rights: for example, establishing steering committees with the authority to challenge project directors, bringing in independent advisors for quality assurance, and ensuring that all critical data (budget forecasts, risk logs, vendor performance metrics, etc.) is available to decision-makers. A culture of accountability means that difficult news is elevated early so that mitigations can be enacted. The CEP’s governance approach, with its strong focus on timelines, encourages us to reflect on the benefits of balancing results-driven ambition with flexibility to adjust plans based on evidence. As one Queensland official acknowledged after the fact, “We are not going to rush and make spurious deadline announcements for the sake of getting a headline” — a recognition that integrity in governance is essential. In digital projects, this might translate to resisting arbitrary go-live dates or feature promises, and instead basing milestones on realistic progress and quality measures.

Finally, strong governance also means building the right capability to oversee the program. In CEP’s case, a new entity (Health Infrastructure Queensland) was created to deliver the projects, but it was established concurrently with the program launch — meaning governance and execution capacity were still maturing when they were most needed. The takeaway for any large transformation may be to ensure your program management office and governance team have the requisite skills, resources, and mandate from day one. If internal capacity is lacking, partnering with external experts or phasing the initiative to allow capabilities to ramp up can be valuable. Accountability, in this context, is about proactively setting the program up for success with competent oversight, rather than assigning blame.

Pillar 3: Market-Aligned Procurement and Budgeting

The CEP experience also shines a light on the need for procurement and budgeting strategies that are grounded in market reality. Large programs can sometimes struggle when planning assumptions do not fully reflect external conditions — for example, expecting contractors to absorb more risk than the market will tolerate, or hoping costs can be contained within predetermined limits despite changing market dynamics. The CEP’s procurement strategy was described by the review as “deeply flawed” for not aligning closely enough with market realities. In 2022, construction costs were rising and skilled labor was in short supply across Australia, yet the CEP set fixed project budgets “in isolation” of those conditions. When actual bids came in, project budgets were exceeded, with initial forecasts of $9.8B needing to be revised to $16–17B to deliver the full scope. The gap — in some cases, 70% more funding required — highlights the importance of realistic budgeting.

Procurement approaches also played a role. Rather than tailoring contracting models to a volatile market, the program sometimes used rigid approaches that placed significant risk on contractors and assumed capacity that wasn’t present. This led some bidders to increase prices or avoid the projects altogether, driving costs higher and slowing progress. For example, the review found that the cost per parking space in the CEP’s contracts ranged from $80,000 to $250,000 — well above typical benchmarks of $40–65k per space. Had standard benchmarks been applied, Queensland Health might have saved substantial sums in car park costs. Instead, by locking in contracts at higher rates, the program saw increased expenditure in this area. This variance suggests an opportunity to strengthen procurement processes, market engagement, and cost controls — including leveraging economies of scale.

For digital health transformations, market alignment is equally critical. Whether procuring a core clinical system, contracting cloud services, or hiring data integration specialists, plans must reflect current market conditions. For example, if there’s a shortage of healthcare IT engineers, this should be factored into timeline and budget expectations. If a vendor’s product doesn’t fully meet needs off-the-shelf, it’s important not to assume a fixed price contract will cover extensive customizations. In practice, this means conducting early market soundings and feasibility studies: understanding going rates, vendor capacity, and risk appetite in the industry. Procurement strategies can then be chosen to distribute risk fairly and incentivize performance — for instance, modular contracts that allow switching out underperforming vendors, or collaborative contracting models in which the government and vendors share in innovation-driven savings.

Furthermore, market alignment may involve phasing or prioritizing investments. If resources are limited, it can be more effective to deliver a few components well (at true market cost) than to spread resources thinly across many projects. The Queensland CEP review noted that the all-at-once approach strained the construction sector’s capacity, suggesting that a more staggered rollout could have reduced pressure and price escalation. Digital initiatives can similarly benefit from sequencing — for example, rolling out a new electronic record system to pilot hospitals first, learning and adjusting costs, then scaling out, rather than signing a single massive contract for a statewide “big bang” deployment. Ultimately, aligning with market reality is about balancing ambition with pragmatism: it’s important to ask, “What will this really take to deliver given the external environment?” The CEP’s budgeting journey invites us to reflect on the value of honest, evidence-based resource planning.

Pillar 4: Stakeholder Engagement and Clinical Co-Design

Large-scale health transformations are not merely technical projects; they are socio-technical. Frontline clinicians, hospital administrators, patients, and community stakeholders will live with the outcomes, so their early involvement is crucial. The CEP experience highlights the complexities of engaging local health service leaders and clinical experts in the planning of new facilities. According to the review, project scopes were developed with a top-down, standardized approach, and sometimes in isolation from local clinician and hospital executive consultation. This led to challenges in local acceptance and later discoveries that standardized designs did not always suit local needs.

For example, in the planning for new hospitals in Bundaberg and Toowoomba, the initial CEP scope was adjusted so that the new facilities would not fully replace the existing hospitals. Earlier business cases had recommended full replacement, but the final approved scope provided only partial relocation — requiring local health services to run two separate campuses in parallel. This decision was made despite local executives raising concerns about extra operating costs and staffing inefficiencies. Their input did not influence the decision at the time. Ultimately, the plan was revised: the new government’s approach now commits to moving all services from the old hospital to the new site in Toowoomba, essentially reversing the earlier scope decision. While this adjustment addresses local needs, it was made after a period of uncertainty. This highlights the potential value of genuine co-design with local clinicians and administrators from the outset.

In digital health projects, stakeholder engagement is equally pivotal. A new clinical information system that disrupts established workflows or is not user-friendly will face resistance, regardless of its technological sophistication. The principle of clinical co-design means bringing doctors, nurses, allied health professionals, and patients into the design and configuration process of digital tools early and often. Their insights can improve the product (making it more user-friendly, safer, and better tailored to patient care), and their involvement can build ownership that pays off during deployment. The CEP’s journey suggests that sidelining local input can create challenges; conversely, transparent communication and willingness to adjust plans based on frontline feedback fosters trust and shared purpose.

Another aspect of stakeholder alignment is managing change through proper training, support, and communication. In the CEP, “poor acceptance” of project scopes hinted at a need for enhanced change management — people felt things were being done to them, not with them. A digital health leader can benefit from investing in robust change management: explaining the vision, listening to concerns, preparing users for transition, and celebrating early wins. Pillar 4, in essence, is about making the transformation a collaborative effort. The CEP experience encourages us to view local health services as true partners; likewise, digital health programs are more resilient when those on the front lines feel a sense of co-ownership in the project’s success.

Pillar 5: Phased Implementation and Adaptive Execution

The final pillar considers how large transformations are executed over time. The CEP’s initial plan was to deliver all projects in one grand push by 2028 — a classic “big bang” approach. This meant planning each new hospital or expansion as a single-stage project, with limited room for incremental delivery or adjustment along the way. The independent review observed that the project delivery strategies did not adequately consider staged delivery; they “unrealistically” tried to pack the entire scope into one development phase. When challenges arose — as they often do in complex projects — timelines needed to be revised, and phased delivery is now being adopted. For example, the flagship Queensland Cancer Centre, originally planned for 2028, is now expected no earlier than February 2031. Other expansions have similarly shifted to later completion dates. In effect, a phased timeline is now being implemented because the initial all-at-once plan proved difficult to sustain.

An adaptive, phased approach could offer several advantages from the start. Phasing doesn’t mean a lack of ambition — it means prioritizing sequence and learning, delivering value in increments rather than betting everything on a distant finish line. If a program is broken into multiple waves — for example, finishing a couple of high-need hospital expansions first, learning from those builds, securing additional funding as necessary, then tackling the next set of projects — it can smooth out demand on resources, provide earlier benefits, and create opportunities to adjust course. The review recommends that future projects be delivered “in a more orderly and staged manner”, with realistic timeframes and better sequencing. The new government has indicated a shift in this direction: Health Minister Tim Nicholls emphasized, “We are not going to rush and make spurious deadline announcements for the sake of getting a headline.” This suggests a move toward more phased, thoughtful execution.

Health Minister Tim Nicholls emphasized:
“We are not going to rush and make spurious deadline announcements for the sake of getting a headline.”

Digital health transformations also benefit from iterative execution models. Large IT implementations have high failure rates when done as big bang rollouts. A more successful pattern is agile or phased delivery: pilot the new telehealth platform in a few clinics before scaling statewide, or implement the electronic medication system in one department to work out kinks before broader deployment. This approach allows for real-world feedback, interim wins to maintain support, and reduced risk. An adaptive mindset also means being willing to pause and reconfigure if something isn’t working. In the CEP, the Redcliffe Hospital expansion faced a challenge with a protected Indigenous scar tree on the planned site; the review recommended halting the project to replan and address scope concerns. This kind of mid-course correction is easier to implement in a phased project structure. In digital projects, it could be analogous to realizing a software module is underperforming and deciding to refactor or replace it in the next sprint, rather than having the entire system go live with a critical flaw.

In summary, agility and flexibility are essential for complex transformations. Planning for phased delivery, building in review points, and being willing to iterate are key. The CEP’s experience suggests that having an “orderly and staged” roadmap is a sign of wisdom — it enables programs to adapt when surprises arise, ensuring resilience rather than rigidity.

Conclusion: Turning Lessons into Leadership

Queensland’s Capacity Expansion Program offers a rich case study in the complexities and opportunities of transformation at scale. A bold vision and significant investment are important, but it is the quality of execution across planning, governance, market alignment, stakeholder engagement, and adaptive delivery that often determines the outcome. For digital health executives, the five pillars outlined above offer a pragmatic framework to reflect on your own initiatives. Are you investing adequately in upfront planning and business cases? Do you have a governance model that surfaces issues rather than suppresses them? Have you calibrated your project to real-world market conditions and smart procurement practices? Are clinicians and end-users co-creators in the journey? And is your implementation strategy flexible enough to absorb shocks and incorporate learning? By thoughtfully addressing these questions, you can help position your digital health program for sustainable success.

Ultimately, large-scale health transformation — whether building hospitals or modernizing information systems — is a high-stakes endeavor. The CEP’s journey highlights both the challenges and the opportunities that come with such ambition. Its lessons illuminate a path forward for all of us. With the right pillars in place, healthcare leaders can steer ambitious programs to deliver real value for patients and communities. Geode Solutions partners with health departments and organizations to put these principles into practice, supporting digital transformation efforts that are grounded in robust strategy and executed with discipline. In an era of rising demands and finite resources, those who learn from cases like the CEP — with humility and curiosity — will be best placed to transform vision into reality through shared leadership and insight.