In the traditional medical organization, researchers are often isolated in their labs, separated physically and psychologically from the clinicians who implement their discoveries and the patients who benefit from them. The Penn State Hershey Cancer Institute in Hershey, Pa., shifts that paradigm by housing researchers and clinicians together in a single building. The layout of the Institute facilitates their interaction, explains Dr. Henry Wagner, Jr., director of radiation oncology, while operational changes bring together many of the specialists a patient will require for treatment in an open, multidisciplinary clinic setting.
This system already is achieving more responsive patient care, says Wagner, and he believes that in the long run, it will contract the time between research innovation and clinical implementation.
“We need to be conversant with our colleagues who spend all their time in the laboratory, who haven’t treated a patient in their entire career, as well as a clinician who doesn’t know molecular biology intimately, but knows patients very well,” explains Wagner. “We need to be able to move back and forth, to talk with each other both formally in conferences and informally in the hallways, common break areas, and cafeterias. We think that this will help to bring better care to all of our patients.”
Opened in July 2009, the building totals 178,000 gsf on five floors, with outpatient activities on the first three floors. Radiation/oncology is housed on the ground floor, with three linear accelerators (plus room for one more), dedicated brachytherapy suite, a CT simulator (with room for an additional one), and pediatric radiation facilities. The first and second floors contain separate lobbies for the Cancer Institute and the existing medical center, the new day hospital, pharmacy, infusion therapy (chemotherapy), multidisciplinary medical clinics, an extensive clinical trial component, and a conference center.
Levels three and four are devoted primarily to research, with 8,700 sf of wet and dry laboratories, 5,300 sf of support space, and 28,000 sf of integrated research and clinical faculty offices on each floor. The research space includes the four main scientific programs of the Cancer Institute:
- Chemical carcinogenesis and chemoprevention
- Experimental therapeutics
- Viral oncogenesis and host defense
- Cancer control and population sciences
The facility also includes core labs with tissue banking and animal research services.
The Institute is a stand-alone building, but it is connected on the ground, first, and third levels to the existing Medical Center hospital, and will be connected on the ground and first floors to a new Children’s Hospital scheduled to be completed in early 2013. All three facilities are arranged along a crescent-shaped loop with separate canopied entrances.
“What you think of as a single building is really more like three buildings in one,” says Michael Hinchcliffe, associate at Payette, the Boston architectural firm that co-designed the building.
Translating Form into Function
The challenge when designing the new Institute was to integrate diverse practitioners who were accustomed to working far away from each other. Clinicians from different specialties were housed in different buildings, researchers had their own labs and offices, and contact between clinicians and researchers was sporadic at best. Merely assigning them to the same building, however, did not mean they would interact. The building was designed to facilitate that interaction with features that are part psychological and part practical.
The most obvious feature is the open “beehive” configuration of the five-story atrium lobby.
“Researchers who work up there look down and see the patients and are reminded why they go to work every day,” says Wagner. “This isn’t just basic science. The patients down in the waiting room look up and realize that they are getting cared for at an institution that values fundamental research and the development of new treatments for them.”
Locating the clinicians and researchers in adjacent offices has the same effect.
“That really mixes things up and increases the chances for interaction and organic exchange in the building,” says Hinchcliffe.
Researchers and clinicians view their worlds differently, and it is important to bring them together as much as possible, Wagner explains.
“In a clinical/medical practice, the focus really needs to be on the individual patient, on treating the disease,” he says. “The researcher is focused on better understanding the biology of the disease. We’re trying to balance the patient’s needs with the need to test novel treatments.”
Differences also exist among the various clinicians.
“Surgeons, medical oncologists, and radiation oncologists tend to see things slightly differently,” says Wagner. Under the previous configuration, it was harder to get them on the same page.
“If I saw a patient and decided she would benefit from the input of a medical oncologist, it would be in a different building that could easily be a quarter-mile away,” says Wagner.
In the new building, disease teams for lung cancer and colorectal cancer, and hematological malignancies like leukemias and lymphomas, now share clinic times. Wagner gives as an example a patient who comes in to see the hematologist.
“He’s treating him for myeloma, he has a painful bone lesion, I’m in clinic that day, (the hematologist) turns to me and says, ‘Could you see Mr. Smith about irradiating the bone?’ It saves the patient an extra trip to the clinic.”
Wagner explains: “On Tuesday, which is lung cancer day, we have the medical oncologist, the radiation oncologist, the pulmonologist jointly schedule patients to see several clinicians in the morning; we discuss their case at noon with radiology in one of the conference rooms, and then come back to the patient that afternoon with a consensus recommendation of what we ought to do. We also bring the clinical research coordinators, people from our clinical trials group, into the clinics so they can hear us discussing the patients. We get direct feedback to link the research mission and the clinical mission.”
Wagner says having ready access to that many clinicians allowed one recent patient to receive treatment two to three weeks faster than it would have happened under the old system.
In addition, exam rooms are universally sized for multidisciplinary use. Work rooms are centrally located to be shared by clinicians, researchers, pathologists, and pharmacists. The building also has many opportunities for casual interaction in lounges, alcoves, and conference and lecture rooms.
It isn’t only the clinicians who are sharing space. Researchers now work in open, multidisciplinary labs that are generically designed to be flexible, and clinical trials offices are shared by clinicians and researchers.
“It has been almost unanimous among the scientists who use this space that, even if they were apprehensive about giving up their comfortable old territory, they like the new open space,” says Wagner. “They particularly like the ability to collaborate by turning their head and talking to somebody who’s 10 feet away, rather than having to walk out of their office, down the hall, and into somebody else’s office.”
Finally, infusion therapy suites are designed to allow patients to interact with each other during treatment.
“We’re beginning to recognize the importance of mutual support by patients of patients,” says Wagner.
A Work in Progress
Challenges are inevitable anytime an organization is asked to rethink the way it operates, but Wagner says the practitioners at the Cancer Institute are discovering the benefits of collaboration.
“If all of the people working together were the same, if they all had the same work styles, the same outlook, identical goals, then this would have been easy,” he says. “You build a building, pour the people in and say, ‘Cure the patients, get the grants,’ and everyone would be happy. But we are a diverse group of people; we are often hard-headed, and we all think that our tools, if not the only ones, are the best ones for solving problems. We also know that not all things that are good by themselves combine well. Just throwing them together doesn’t necessarily give you meaningful results.”
“There was a little bit of ‘turfi-ness,’ with people wondering, ‘who’s clinic is it?’” Wagner continues. “It’s everybody’s clinic. Dealing with common space can often be difficult, but it’s working better.”
They are still struggling to bring together specialists who work on different schedules and may have multiple competing responsibilities both in the Cancer Institute and the rest of the Medical Center. Surgeons, for example, are assigned a certain time in the operating room.
“Changing that schedule, which may impact dozens of individuals, is like changing the course of a large river,” says Wagner.
As the school looks to the future, Wagner says they are starting to plan for the next generation of clinicians who will inhabit this building.
“We are developing a course on translational research for PhDs, post-docs, medical and surgical oncology fellows, radiation oncology residents, and junior staff, to bring them together early in their career,” says Wagner. “It’s not terribly helpful to bring mid- and late-career people together and tell them to collaborate. You need people who are training together and forging partnerships. This is the beginning, not the end.”
By Lisa Wesel
This report was based on a presentation given by Wagner, Hinchcliffe, Richard Aradine, and Sho-Ping Chin at Tradeline’s Academic Medical and Health Science Centers conference in October 2009.
Architect: Payette, Boston
Associate Architect: Array Healthcare Facilities Solutions, King of Prussia, Pa.
Mechanical, Electrical, Plumbing, Fire Protection: Bard, Rao + Athanas Consulting Engineers, Watertown, Mass.
Structural, Civil and Traffic Engineers: Gannett Fleming, Harrisburg, Pa.
Landscape: Hargreaves Associates, Cambridge, Mass.
Parking: Walker Parking Consultants, Wayne, Pa.
Construction Manager: Gilbane Building Company, Harrisburg, Pa.