Hospital planning and design projects are known for their complexity, partly attributed to the many stakeholders involved. This study aims to understand how a Dutch hospital project, with transformative change goals for its future healthcare delivery, dealt with their stakeholder engagement in the project’s planning and design phase. This study addresses heterogeneity in stakeholder relationships, an underexplored aspect within stakeholder engagement literature. A qualitative study was conducted on the stakeholder engagement during 10 years of hospital planning and design. We used an abductive approach by reviewing project documentation and transcripts of interviews with project stakeholders (n = 22) to reconstruct how the project leadership dealt with the challenges of heterogeneity in the project’s specific context. This study explores dynamism and pluralism within the relationships with seven distinctive stakeholder groups from the hospital’s multi-stakeholder setting, uncovering engagement strategies based on unique combinations of actor and process-specific characteristics. Wider transformative change goals added to the challenges faced in ownership and alignment of goals. Findings highlight the strategies and competencies the project’s owner (and leadership) deployed, such as adapting the project organisation’s structure, investing in an in-house community of practice with a dedicated stakeholder engagement role and fostering enduring collegial relations and commitment.