The Architecture Of Change

Towards a New Cancer Center Design

A building is more than it seems. It is an artifact – an object of material culture produced by a society to fulfill particular functions determined by, and thus embodying or reflecting, the social relations and level of development of the productive forces of that society….They are also physical expressions of a way of life. Buildings reflect not only culture, however, for they are engaged in reproduction of social relations, both as monuments or more prosaic signs and symbols in communication of social meaning, and through their relations of separation and containment. A building is invested with ideology, and the space within, around and between buildings is both produced and producing. “

(J. Goss,1988 The built environment and social theory: Towards an architectural geography.)

Whether building new, adding-on or renovating in-place, many of our clients have shifted emphasis and capital in the last 5 years toward Cancer programs on their campuses. Each of these building scenarios differs opportunities to use architecture as a change agent on your healthcare campus- to reflect the goals of the program and institution.

Through 5 case studies:

1. The University of Wisconsin Cancer Centener - Johnson Creek, WI
2. Froedtert and the Medical College of Wisconsin Clinical Cancer Center- Milwaukee, WI
3. Advocate Lutheran General Hospital - Park Ridge, IL
4. Prentice Northwestern Women’s Hospital- Chicago, IL
5. Northwest Community Hospital- Arlington Heights, IL ,

We will examine key drivers and attributes of these designs as they relate to cancer center design. In all of these examples, regardless of the specific circumstances of the project, as designers there are 3 things that we are motivated by.

Challenging existing paradigms & creating organizational effectiveness

Options that are developed and evaluated include physical variables, but will not be driven by these physical variables alone. Vision, demand, regulations, operations, human resources, technology, physician referrals, resources and finances are addressed in order to develop the appropriate program and design solution.

photo: Craig Dugan- Hedrich Blessing Photography

Imparting Agility

Our approach is one that identifies the parameters of change, bracketing a range of possibilities and creating an environment that can respond and adjust effectively to that range. Clearly, with the completion of the Human Genome Project, genetic therapies will increase in availability and importance in the treatment of cancer, resulting in a realignment of space needs. This of course must be balanced with the fact that, currently, design of space for cancer treatment and prevention, involves some very specific and unique components. The goal is providing for agile facilities that can adapt, grow, condense, and evolve over time.

Creating an Exceptionally Positive Patient Experience

We firmly believe that good healthcare planning and design are rooted in how people intuitively and instinctively react to a space. Patient satisfaction surveys have repeatedly shown that the aesthetics of a facility will affect a patient’s choice, but this is generally tempered by their personal experience within the facility. Factors such as convenient parking, ease of registration, waiting times, easy travel distances between departments and clear and understandable wayfinding all play a more critical role in a patient’s perception of a facility.

Planning and Design Issues to Consider

Arrival, Adjacencies and Flow

Successful healthcare design and planning assemble spaces appropriately, matching care model to facility and volumes and utilization to room quantity, so that caregivers spend their time providing care instead of traveling between equipment, the workplace and the patient. Increasing demand for cancer care services and inefficiencies caused by disparate locations of cancer-related services led Froedtert Hospital and the Medical College of Wisconsin to expand and consolidate all cancer programs into a single location on the academic medical center’s campus. The 466,000 sf facility has a freestanding presence, yet links back to the current program and its abundant resources. Key features of the expansion include a dedicated cancer center building with its own entrance and parking to ease access for patients; clinical care for all types of cancer through 12 disease-specific, multidisciplinary cancer programs; support services such as laboratory, imaging, dietary, psychosocial and pastoral care; and space for research facilities and international cancer data registries.

At Froedtert and the Medical College of Wisconsin Clinical Cancer Center the building’s clear navigation and wayfinding sequence actually begins when the patient picks up the phone to make the appointment- a clinical care coordinator- a kind of personal concierge-helps coordinate all appointments and guides you through you treatment journey. The Clinics utilize a “hub” model that increases interaction among patients, caregivers, and researchers by improving adjacencies through proximate locations, which allows for improved levels of care, efficiency, and staff satisfaction.

Froedtert and the Medical College of Wisconsin Clinical Cancer Center- Overall building form

The new facility houses services often found within a comprehensive cancer care facility, including the clinics developed around a model that increases interaction among patients, caregivers, and researchers for improved care, efficiency, and satisfaction. Other elements include a Quality of Life Center, Image Recovery Center, Breast Center, Day Hospital, centralized Procedure Suite, Radiation/Oncology, Phlebotomy, Education Center, and dedicated under building parking for cancer patients.

Froedtert and the Medical College of Wisconsin Clinical Cancer Center- The clinical spaces sit atop conveniently located patient parking at eh base of the building.

A gracious lobby welcomes guests by providing natural daylight and a visual connection to the outside. The hospital considers visitor access to outdoor areas to be a priority; guests can enjoy views of the neighboring wetlands through the glass facade.

photo courtesy of Craig Dugan- Hedrich Blessing Photography

Froedtert and the Medical College of Wisconsin Clinical Cancer Center- a comfortable, bright welcoming space greets patients and their families.

The resulting design favors neither doctor, nor patient, nor researcher but creates a balanced environment that meets the needs of all users. There is a connection to humanity within the building, an opportunity to interact with nature, views, natural light, and a sense of place and hope.

Separation by Acuity Level

A comprehensive cancer center serves patients through multiple levels: screening, diagnosis and treatment. For this reason, it is important that the physical environment makes patients feel comfortable through all levels of care and associated anxiety. It is our goal to develop innovative design solutions that allows these patient groups to coexist comfortably without added stress.

A separation of program elements can be a challenge related to adjacency and travel distances for patients and staff. Yet, a challenge can be overcome through integration of facility and campus design, graphics, obvious and immediate access to transportation that links facilities and a friendly face at the front door. All of these factors contribute to an ideal experience for all customers: patient and family, physician and researcher, caregiver and technician.

The Center for Advanced Care at the Advocate Lutheran General Hospital is an addition to and renovation of the West Pavilion, an older, under-utilized building in a prime location on campus. The existing building suffered from limited floor-to-floor heights, scarce natural light and poor air circulation. The design team responded by creating an open, light-filled consolidated, multidisciplinary outpatient center that separates the major functions while maintaining a unified design.

Advocate Lutheran General Hospital Center for Advanced Care- Cancer programs are veiled behind a fritted glass exterior wall.

The expanded facility provides outpatient services for medical and radiation oncology, imaging (CT scanning, MRI, nuclear medicine and general radiation) and a breast health center. The major service lines are expressed as separate entities, each with its own entry, formal language and material identity. Direct entrances via the adjacent parking deck protect patient privacy, yet the main circulation spine with a light-filled, three-story atrium creates a sense of community. Accommodation for the future was achieved through the use of a clinic module that allows flexibility for changing care models and includes areas for growth.

Advocate Lutheran General Hospital Center for Advanced Care- a small atrium creates a sense of community inside the building while not sacrificing patient privacy.

Consider Staff Recruitment and Retention

Staff come to and stay with organizations that make them feel valued. Staff shortages driven by higher patient acuity, the aging of America (increased demand for caregivers and decreased supply), a nursing workforce with an average age in the mid-forties, non-competitive wages and benefits, poor job design and working conditions and exponentially increasing paperwork with lacking IS support have made attracting and retaining healthcare professionals an essential part of every operation. Investments in facilities that introduce contemporary configurations and adjacencies, incorporate new technology and create a state-of-the-art workplace strengthen a hospital’s position. By coupling these with an operating model that is staff friendly, new facilities can become a recruiting tool.

The UW Cancer Center at Johnson Creek is owned and operated by the joint venture partnership of UW Health, Fort HealthCare and Watertown Memorial Hospital. The design of the center was developed to meet the center’s goals, which include state-of-the-art diagnostics and treatment, efficient and seamless care, a human experience for both patients and staff and recruitment of top clinicians.

The building has won many awards and is seen as a major asset in recruiting for this rural cancer center. It affords the staff the ability to connect remotely with their peers in the more urban healthcare settings through video conferencing and electronic records.

University of Wisconsin Cancer Center at Johnson Creek - Driven by the programmatic needs of the interior treatment spaces and inspired by the surrounding rural Wisconsin woodlands, the single story structure is designed to be an iconic building in the community and aims to maximize the sense of connectivity between the soothing interior healing spaces and surrounding natural environment.

The interior spaces are designed to convey a sense of intimacy with a soft color palette, comfortable furnishings and natural light. Patient options are key in the design and include the choice of private or open chemotherapy infusion bays and control over lighting, scenery and music in the linear accelerator vault. The conference room is designed with flexibility in mind to accommodate multiple functions including conferencing, seminars, education, massage therapy and acupuncture. Clear views of the wooded hillsides are available from most spaces within the center. Access to winding paths and natural landscapes create areas for relaxation.

University of Wisconsin Cancer Center at Johnson Creek- A natural , simple palette of materials makes the building feel at home in its rural landscape.

Chemotherapy Infusion Bay Design & Control of Environment

With therapy lasting up to eight hours, design of the chemotherapy infusion bay needs to create a tranquil place. Through our experience, we have found that a large open room filled with IVs can be dehumanizing. Rather, the design should make the patient experience a priority and include flexibility in the levels of privacy. Therefore, we have developed variations on the private bay with views to nature, amenities for family and friends and retractable walls, screens and/or partitions, which allow for interaction between patients and reinforce a sense of community.

The patient needs to have a sense of control over his/her environment – from temperature to light control to privacy. Privacy is often one of the greatest challenges; how do we design the space to allow a patient privacy during periods of stress or extreme illness, but not exclude him/her from the community of patients and caregivers?

At Froedtert, the inclusion of a Day Hospital serves the needs of patients who may not tolerate treatment well and need the equivalent of inpatient care. The Day hospital meets the needs of these patients, providing high level care in a comfortable environment while allowing them to go home a tonight. The day Hospital offers patients a variety of settings also- from social to private- enhanced by natural light and beautiful views.

photo courtesy of Craig Dugan- Hedrich Blessing Photography

Froedtert and the Medical College of Wisconsin Clinical Cancer Center Day Hospital – the light filled corridors to the Day Hospital offer places to sit and unobstructed views to the neighboring wetlands.

Froedtert and the Medical College of Wisconsin Clinical Cancer Center Day Hospital- Patient control of privacy and constant monitoring by staff.

photo courtesy of Craig Dugan- Hedrich Blessing Photography

Froedtert and the Medical College of Wisconsin Clinical Cancer Center- Infusion Bays

University of Wisconsin Cancer Center at Johnson Creek - Infusion treatment bays are located along the perimeter and offer patients visual connectivity with caregivers, control over environmental conditions and options for levels of privacy. There is a sense of integration with nature within a serene interior setting.

Family Support

The family plays a critical role in the patient’s support team. Infusion bays, post-operative units and short-term stay rooms must be large enough to accommodate family members and have such conveniences as television, Internet and comfortable furniture that accommodates sleeping. Space needs to be dedicated to education and resource centers in areas of the project that are communal and immediately accessible- access to information not only from doctors and caregivers but form printed and digital media at these times of stress is essential.

At the Lutheran General Hospital Center for Advanced Care a modestly scaled, semi enclosed resource center occupies a key location on the ground floor. Likewise at the Northwestern Memorial Hospital's Prentice Women’s Hospital, their library and resource center plays an important role in educational outreach for their clinical programs.

photo courtesy of Steve Hall - Hedrich Blessing Photography

Advocate Lutheran General Hospital Center for Advanced Care Resource Center – a comfortable, modestly scaled library accessible by staff, patients and their families.

University of Wisconsin Cancer Center at Johnson Creek Waiting Area and Community Resource Center - The subtle color palette creates a canvas-like backdrop that uses natural light and colorful woodland views to bring life and character into the space. The multi-purpose space can be used in any number of ways; a waiting area, educational resource center, “cyber café”, or event space.

photo courtesy of Craig Dugan- Hedrich Blessing Photography

Northwestern Memorial Hospital’s Women’s Hospital Resource Center- located in the main lobby of this urban healthcare center, the resource library is the hub of educational activity for the facility.

Caregiver Accommodations and Communication

Just like patients and their families, caregivers must also have comfortable, convenient places to decompress. They need adequate and efficient storage and easy access to state-of-the-art technology. Most important in the treatment of cancer are the ease and clarity in the blending of efforts of clinicians, researchers, allied health professionals and other care team members. The environment must allow for the affinities of all caregiver team members to serve the patient optimally in a coordinated manner. This includes facilities where specific types of carcinomas can be identified and a variety of treatment types are offered, ranging from surgery to chemotherapy to radiation therapy to genomic therapy.

University of Wisconsin Cancer Center at Johnson Creek - Recruiting and retention issues influenced the creation of a teaming area that encourage collaboration, offer a place of respite with access to natural light and views, and maintain a consistent level of finish quality and detail.

Leading-Edge Diagnostics and Treatments

The Center needs to incorporate the technological modalities and interventional/non-interventional techniques required for early diagnosis and the quickest treatment possible, while providing flexibility to accommodate future modalities.

These needs may include:

• The continuing need to understand the biology of specific disease processes
• The development and future incorporation of more sophisticated imaging technologies
• The continuing development of surgical and stereotactic radio surgical technologies and techniques
• New computerized treatment planning and simulation systems
• The availability and selection of therapies that destroy the disease mechanism or help ease symptoms and increase the quality of life for patients

The University of Wisconsin Cancer Center at Johnson Creek is a rural-access cancer center providing much needed care to an underserved population. The center is connected electronically with its university counterparts through electronic records and consults offering world class academic healthcare in a rural setting.

University of Wisconsin Cancer Center at Johnson Creek- Simply appointed interior exam rooms offer privacy and protection to the patient while placing caregivers close to the work areas which fosters communication and collaboration among medical personnel during patient consults.

Linear Accelerator Design

Operationally, we have explored many layouts that arranged the linear accelerator vault, control area, treatment planning and patient waiting in order to optimize flow and match the model of care adopted by the facility. Throughput and movement studies have been conducted and reviewed, so as to balance patient comfort and privacy with staff adjacency needs and facility volume requirements. We have gone so far as to analyze the traditional maze entry design versus lead shield door systems. The traditional maze, where a cast-in-place concrete, zigzag path prevents stray radiation from finding its way out of the linear accelerator vault, can decrease operational efficiencies and increase the necessary space. Options to offset this inefficiency include lead shielded sliding and swing doors.

Typically the amount of concrete involved in the construction of the linear accelerator vaults in quite large such that placement of the vaults on the ground level of below is most efficient such as in the University of Wisconsin Cancer Center at Johnson Creek. Occasionally, adjacency to an existing Cancer program makes it necessary to elevate the vaults above the ground level as in the Froedtert and the Medical College of Wisconsin Clinical Cancer Center.

Equipment selection will drive the size of the vault, its height requirements and the mechanical system necessary for cooling. Careful consideration to lighting, color and materials can create a pleasant atmosphere – one of healing and hope.

University of Wisconsin Cancer Center at Johnson Creek- Linear Accelerator Vault

University of Wisconsin Cancer Center at Johnson Creek- Linear accelerator vault under construction

Froedtert and the Medical College of Wisconsin Clinical Cancer Center- Third floor linear accelerator vaults under construction.

Surgical Design

Since a new generation of technology is created every 18 months, it is a challenge to know exactly what evolution or revolution will happen in technology that will impact healthcare practices. OWP/P designs surgical environments for a new definition of flexibility and a new integration of building systems for operating rooms and their adjacent ancillary spaces, striving to create an optimal balance between high-touch personnel and high-tech equipment.

We recommend including soft or shell space in the design of healthcare facilities, which allows for operational, service and infrastructure flexibility and change over the life of a building. Therefore, we believe surgical room design should be based on a module sized for future needs, so that the function can be modified over time without major alteration to the size or shape of the space. Functions can then be moved without reconfiguring the physical setting.

Advocate Lutheran General Hospital Inter-operative MRI and Telemedicine Operating Room

Translational Research and Laboratory Design

Although fundamental insights into the mechanisms of disease have accelerated in recent years, transferring this knowledge into practical advances in health care has moved more slowly. The National Institutes of Health and other public and private organizations support basic biomedical research, while industry supports the commercial development of medicines and medical products, but the vital bridge between these areas remains underserved.

The Institute of Medicine’s Clinical Research Roundtable (CRR) produced a report in March 2003, based on three years of study by the full CRR, which determined that the U.S. system to get medical advances out of the lab and to patients is broken. One bottleneck cited is the point at which laboratory findings – proof of new scientific concepts – are translated into human studies. Another barrier identified is that once something gets reported as a medical breakthrough, it is difficult to get doctors to change what they are doing. And beyond that, how is it determined that a new breakthrough is better than existing treatments? The CRR felt those questions are not being answered nor addressed with the level of commitment we see in basic science.

This translation of basic research knowledge into improved patient care, as well as the translation of clinical insights into hypotheses that can be validated in the laboratory, are additionally threatened by changes in the financing of medical research and health care. The rapid growth of managed care, for example, has limited the financial resources available to many academic medical centers, which historically have been at the forefront of both basic and clinical research. Consequently, many physician-scientists, who play a critical role in identifying clinical questions and implementing advances in the basic sciences, have fewer financial resources, less time and smaller patient populations available for clinical studies.

The transfer of knowledge from scientists to clinicians to patients, including from lab to bedside treatment, is critical in the successful treatment of cancer.

Environmental Sustainability

Hospitals are taking up green practices, whether incrementally or from the ground up. These hospitals are managing to lower energy bills, reduce waste and achieve healthier indoor air, making good sense for the health of the entire community: patients, staff and visitors. It is the rare case for us not to pursue LEED® (Leadership in Energy Design) certification for a project without clients and even in these cases the project is typically designed to LEED® standards.

In the very rare case where this is not on a clients radar screen, simple design changes can work wonders, too. Studies have shown that poor indoor lighting increases levels of stress in hospital workers, leading to compromised medical care. "Daylighting" (that is, bringing daylight indoors with enlarged windows, light wells, clerestory windows and reflective surfaces), not only improves work performance but has been shown to improve patient recovery rates, while saving energy.

The scale of healthcare work in this country makes this shift towards sustainability an important change agent in the building culture of healthcare.

Generally we have found that the following points are the ones most readily addressed within the healthcare settings in pursuit of a sustainable architecture:

Sustainable Sites

• Reduce storm water runoff with green roofs, rain gardens permeable paving
• Provide showers, changing facilities and bike racks for 5% of staff
• Use light colored paving and roofing materials to reduce heat island effect

Water Efficiency

• Irrigate plantings only with recovered storm water
• Use plantings which are more tolerant of drought conditions
• Use low-flow plumbing fixtures and timer faucets where appropriate

Energy and Atmosphere

• Increase building energy efficiency - equipment and refrigerant selection and building design
• Increase daylight opportunities, light to apertures to building cores
• Reduce indoor VOCs and pollutants
• Optimize equipment and lighting

Materials and Resources

• Develop hospital recycling program for paper, cardboard, plastics, metal and glass
• Utilize recycled materials in the project where possible
• Recycle construction waste from the project
• Incorporate regional materials in the project where possible
• Use FSC Certified Wood Products

Interior Environmental Quality

• Ban smoking within the facility (ALGH campus standard)
• Monitor air quality
• Implement indoor air quality plan during construction
• Flush out building after construction and prior to occupancy
• Use low VOC paints, sealants, adhesives, carpeting and composite wood products
• Provide more lighting and thermal comfort control for patients and staff
• Increase views to exterior and daylighting in the central core of the plans

We have recently designed what is anticipated to be the first LEED® Gold hospital in the Midwest- Advocate Lutheran General Hospital –including a 34 bed oncology and bone marrow transplant unit. With an environmental focus on, among other things, water efficiency and a sustainable site, the project has dramatically reduced water runoff into the community.

Advocate Lutheran General Hospital- Through use of native plantings, permeable paving and green roofs the project has substantially reduced water runoff.

Due to open this fall, the design of Northwest Community Hospital’s new Patient Care Tower Renaissance Project and its Oncology floors follows suit with a focus on local ecology irrigating drought tolerant native plantings with recovered storm water. Connection to the outdoors is further reinforced through generous daylighting of spaces and the inclusion on exterior balconies on the patient floors.

photo courtesy of Brian Bassett

Northwest Community Hospital Renaissance Project Patient Care Addition- Balconies off of patient room floors allow access to outdoors.

In addition, the recently-completed parking deck, which is also part of the hospital’s Renaissance Project, is pursuing LEED® certification. Adding 750 new parking spaces to this growing campus. A number of environmentally sustainable strategies were used in the design of the garage, contributing to the overall plan to achieve a LEED® silver rating for the Renaissance project. The landscaping surrounding the structure is part of a campus-wide plan to sustainably deal with stormwater. Rain gardens and bioswales slow the rate that stormwater enters the sewer system, and recharge the natural groundwater. Native plant species are used to reduce the need for irrigation. The impact of “heat island effect”- the result of structures absorbing and retaining heat, reaching temperatures higher than the surroundings – is minimized by using light colored concrete on the top level of the garage. A number of energy saving strategies are also employed including occupancy sensors for interior lighting and energy efficient ventilation fans in the lower levels. Bicycle parking is provided inside the garage to encourage alternatives to automobile use. Finally, light pollution is reduced by using full cutoff fixtures that direct light down to the surface being illuminated rather than up towards the sky.

Northwest Community Hospital Renaissance Project Parking Structure – a focus on groundwater management through bioswales and plantings

At Northwestern Memorial Hospital's Prentice Women’s Hospital, an entire floor in the new facility consists of a breast imaging suite, which includes 28 diagnostic and screening mammography rooms, five stereotactic rooms, eight ultrasound diagnostic rooms and an MRI. This floor also includes a breast surgery center and a breast oncology suite with 15 infusion spaces. Two linear accelerators located on the lower concourse are dedicated to the treatment of breast cancer. The fourteenth floor is dedicated to inpatient gynecological oncology and the 16th is inpatient medical oncology.

It is located on a premier site near downtown Chicago with sweeping views of Lake Michigan and convenient access to nearby parks and transportation. The 940,000 SF, 328-bed, 17-story hospital is one of only a handful of free-standing hospitals dedicated to providing care to women in all stages of life. The state-of-the art facility will focus on energy efficient, environmentally responsible and healthy building design solutions. One of the largest medical facilities in the country to achieve LEED®

Silver Certification, more than 3,836 tons of debris was removed from the construction site. Of that amount, 84% was recycled (steel, copper, glass) or reused (concrete as filler for other construction projects). With large windows to maximize city or lake views and provide ample daylight, the building has seen a 32% reduction in total building energy cost for lighting and a 50% savings in lighting costs compared to the prior facility.

Northwestern Prentice Women’s Hospital

photo courtesy of Craig Dugan- Hedrich Blessing Photography

Northwestern Memorial Hospital’s Prentice Women’s Hospital- Patient room with view out over green roof.