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Rapid advancements in blockchain technology transform various sectors, attracting the attention of industrialists, practitioners, policymakers and academics, and profoundly affect construction businesses through smart contracts and crypto-economics. This paper explores the blockchain innovation ecosystem in construction.

Through a qualitative study of 23 diverse interviewees, the study explores how open or closed the blockchain innovation ecosystem in construction is and who its emerging orchestrators are.

The data showed that construction aims towards an open innovation blockchain ecosystem, although there are elements of hybridisation and closedness, each system pointing out to different orchestrators.

The study has implications for governments and large companies in construction, showing that open innovation initiatives need to be encouraged by policymakers through rules, regulations and government-sponsored demonstrator projects.

The data showed that there is lack of readiness for business model change to support open innovation blockchain ecosystems in construction.

This is the first study applying the open innovation theory in the construction industry and sheds light into the phenomenon of blockchain, suggesting routes for further democratisation of the technology for policymakers and practitioners.

Off-Site Construction (OSC) has received much government and public attention during and after COVID. Building Information Modelling (BIM) is an initiative discussed widely to promote OSC implementation. Although many policy promotions have been published, there are many challenges to implementing BIM and OSC in real life and questions of whether they really offer value to healthcare design professionals. This research aims to investigate BIM and OSC to understand their commonalities and differences of challenges by collecting empirical evidence from China’s healthcare construction.

This exploratory research adopted a mixed method with a questionnaire survey and interviews. A total of 261 questionnaires were received (with 183 valid), followed by 31 semi-structured interviews.

This research reveals that although both OSC and BIM face similar adoption challenges and suspicious attitudes in real-life projects, their challenges’ connotations and reasons are different. OSC faces scepticism for its customisation costs and technical constraints, while BIM is seen as limited in utility and complex to integrate. Highlighting these as socio-technical challenges, the research advocates for an integrated framework to effectively implement OSC and BIM, addressing both technical and collaborative needs in healthcare construction.

This research examines OSC and BIM within the context of healthcare construction, a focus that is relatively underexplored. The research provides a juxtaposition of the perceived and practical challenges of adopting these technologies, revealing a gap between the industry’s expectations and the current capabilities of OSC and BIM, thereby contributing to the development of modern methods of design in healthcare.