The first 8 years of the new millennium witnessed one of the largest construction booms in healthcare since the 1950s, and until the bottom dropped out of the economy in fall of 2008, no one expected the boom end anytime soon. According Jennings and Hughes (2009), $41 billion were invested in hospitals and clinics, and an estimated $40.7 billion-worth of construction was underway by the fourth quarter of 2008. It was estimated that by 2020, $200 billion would be spent for healthcare facility construction. With the huge declines in the stock market, the credit crisis that has all but eliminated lowcost borrowing, states threatening bankruptcy, and the possibility of radical healthcare reform, uncertainty about the future now prevails. All healthcare system leaders have had re-examine their priorities and their approach capital allocations for improvements in the physical plant, equipment, technology, electronic medical records systems, and information systems. Some board members and executive teams have elected complete projects already in progress, while others have put the brakes on planned projects with indefinite completion dates preserve cash, reassess financial capabilities, leverage existing capital investments, and focus on core operations sustain operating margins.These uncertain times have challenged both the healthcare industry and the field of healthcare design and construction. We feel uncertain as we anticipate and consider new government regulation of healthcare, changes in the payer industry, competitor strategies that can affect market share, proposed staffing ratios legislated for nurses, emerging technologies, and of course, the national economy (Jennings & Hughes, 2009). Executive teams find themselves in the throes of managing the impossible, making decisions without all of the necessary data, and taking calculated risks while confronting a very obscure future. Not only do they wrestle with the question of to build or not build, but also how access capital in an uncertain market and how cut the costs of existing and projected capital projects minimize overall financial exposure. All the while, healthcare leaders also grapple with the potential longterm risks of not investing in capital projects.Capital Planning and Debt FinancingHealthcare construction projects can be financed in a number of ways-bond investors (retail and institutional) commercial banks and direct lenders (off-balance-sheet lenders, secured lending companies, and equipment leasing companies) name a few-but all require a good bond rating from rating agencies such as Fitch, Moody's, and Standard & Poor's. Unfortunately, credit rating downgrades for healthcare organizations have significantly outpaced upgrades since 2006, which dramatically affects hospitals' bond ratings and credit interest rates (Zieger, 2008). Certainly, credit-worthy organizations have improved capital market opportunities such as access loans and lines of credit from commercial banks, flexible financing options, and less restrictive bond documents and operating covenants, but in the current tight market where uncertainty prevails, even credit-worthy organizations are struggling finance their major expansion or replacement projects (Hemker, 2008). …