Planners were into schematic design for the University of Texas M.D. Anderson Cancer Center's nine-story, 782,000-square-foot Ambulatory Clinical Building (ACB) when tropical storm Allison struck Houston in June 2001.
The architects designed the building with underground parking to reduce the number of visible parking garages on campus and make the site easier for patients to navigate. After Allison, they realized they had to address the potential for floods, too.
They ultimately decided to use a series of passive and active flood restraint measures to make underground parking possible despite the site's low elevation.
Drivers entering the garage first go up and over a berm before driving down into the parking area.
The site has a protective bank up to 46 feet above sea level, two feet higher than the high-water mark from Allison. It also has floodgates that can be put into place to protect the building from waters up to 50 feet above sea level.
Additionally, the building's entire mechanical infrastructure, including all major medical equipment, is above "elevation 50." In the event of a flood, "the only thing we could lose is the gear on three [out of 27] elevators," says ACB Project Director Janet Sisolak.
Getting the job done
M.D. Anderson uses a "bench to bedside" model of cancer research and treatment in which researchers and clinicians work closely together to get new treatments from the lab to patients as quickly as possible. For the ACB project, which is the largest building on the M.D. Anderson campus, the center took a similar attitude toward getting the job done.
The ACB went from planning to completion in less than five years--half the time projected for a building of its size. Sisolak jokes the project "was like getting on the Autobahn only to realize there are no exit ramps."
The cancer center needed the additional space quickly because they were treating more patients than expected. In 1992, they were told to plan on a 30 percent reduction in patient activity with the advent of managed care, and they downsized accordingly. However, patient volume increased 30 percent. "So that left us with a huge, huge deficit in terms of space," says Sisolak.
The center, which has been rated by U.S. News & World Report as the best comprehensive cancer hospital in the nation for four of the past five years, could not accept all the patients who wanted to be treated there.
"Because of that, we decided to fast track [an expansion] project," she explains. Using a design-build process, they hired Kaplan-McLaughlin-Diaz (KMD) Architects, San Francisco, and Houston-based FKP Architects Inc. to design the ACB, and Hensel Phelps Construction Co. of Greeley, Colo., to build it.
Along the way, the design team faced many challenges in addition to the underground parking quandary.
For instance, because it was important to maintain the connection between the center's clinical areas and research laboratories, planners chose to build on a 22-acre site right across the street.
This, in turn, required the construction of a 1,460-foot-long skybridge between the ACB and the main campus to facilitate movement between the two. The bridge is 25-feet wide to accommodate golf cart and pedestrian traffic.
However, the vast majority of the design and construction challenges centered on the facility's wide variety of medical equipment, which dwarfs the selection found in many entire cities.
Stacked technology
"Most often, the typical planning strategy would be to position imaging equipment and linear accelerators on the ground floor," says Lisa Charrin, AIA, ACHA, president of Equipment Collaborative (EC), a Houston-based subsidiary of FKP, which led the equipment planning, procurement and installation for the project. "In the ACB, everything needed to be elevated for [flood control] reasons," she says.
But also, she says, "had we placed all the major equipment at ground level, patients would have had to walk miles." She notes that while most imaging departments have only one or two magnetic resonance imaging (MRI) rooms, the ACB has an entire department for each modality, with five computed tomography (CT) rooms, six MRI rooms, four positron emission tomography/computed tomography (PET/CT) rooms and 11 nuclear medicine rooms, among other routine general radiographic rooms, mammography, ultrasound and invasive radiology areas. "It wasn't feasible to place all of it on one or even two levels," says Charrin.
By stacking the major medical equipment on different floors, the architects were able to keep clinics adjacent to related diagnostic and treatment space.
Rick Harris, AIA, ACHA, associate principal and project manager for FKP, says, "The initial concept was to keep the services needed by the patient close to the patient. In many modalities, the clinic specialty that's on a certain floor has its heavy diagnostic treatment area on the same floor. Patients don't need to be walking, riding elevators and getting confused."
"It's very hard to get lost in the new building," says Sisolak. "Every [treatment] floor is laid out exactly the same."
The major medical equipment was installed on the north side of each floor. This side of the ACB was designated a heavy load zone to support the large, vibration-sensitive equipment, along with concrete and lead shielding (lead shielding alone added 3.75 million pounds to the building's weight load). Floors on the north side of the building can withstand up to 150 pounds of pressure per square foot.
The footings and foundations on the building's north side were sized based on a "worst-case model" of projected equipment size, says Charrin.
Planning ahead
"We're always challenged when starting a design project several years out from occupancy. The timing on imaging is T-minus six months, so you want to be buying six months prior to when you need it to arrive. If you're buying a year out, or more, you're potentially not getting the most advanced equipment," Charrin says.
To give the builders a basis for design while allowing the cancer center to buy equipment later in the process, EC gathered data from several medical equipment manufacturers. "We said, 'Give us your heaviest MRI, give us your largest MRI.' It may or may not have been the same model. We structured for the worst case for weight and then the structure started being built. We sized the rooms on the worst-case footprint," she says.
"We were actually dealing with equipment that was not on the market yet," says Harris. To determine likely dimensions for equipment under development, the team worked with early drawings released to them by vendors.
The rooms were constructed around common requirements of different models.
"For example," says Charrin, "we established one isocenter for the linear accelerator rooms and overlaid two different models to be sure clearances and shielding would work for either. In the case of an MRI," she adds, "there's a quench duct that goes above the magnet. Each of the different models had a different location for that." Rather than roughing in three ducts, the planners decided to fix them all at the same point. Wall placement was then determined based on each model's dimensions from that point.
Charrin says, "We took the same approach to overlay requirements and planned to accommodate different models." To meet varying infrastructure requirements for different models--such as voltage--the engineers roughed in multiple systems.
The building has several other structural features designed for the major medical equipment. For instance, the radiation treatment areas are lined with lead; siliconized steel and copper linings block the magnetic field and radio frequency waves in the MRI rooms. The builders used stainless steel or aluminum in these rooms for fire sprinkler lines and all other items that are normally carbon steel because of the powerful magnets in the MRI machines.
Among infrastructure requirements, the engineers installed transformers and air handlers large enough to provide for current and future needs. "The strategy was to build in the infrastructure that would not be easy to change in the field one or more years down the road," says Charrin.
ACB Facility Manager Stephen Stenhouse says the building has four 3,200-amp transformers at 4,160 volts each--two on each side. It also has 36 air handlers that operate at a rate of 30,000 to 40,000 cubic feet per minute. There are four air handlers on each of the clinical floors (floors four through eight); the remainder are for the public floors, pharmacy and outside air.
The building's flexible physical structure and engineering features allowed the cancer center to consider several manufacturers and models when purchasing medical equipment.
Harris says, "[The center] went into this knowing there would be some renovation expenditures adjusting the rooms to deal with the different modalities. However, it was worth the risk and worth the investment to get the latest and greatest technology."
Fostering flexibility
This type of thinking will also make it easy for the cancer center to update equipment or compare different models.
For example, the center uses mammography equipment from three different manufacturers to take advantage of features that may be more specific to one patient type than another. "Some are better suited for screening versus diagnostics and some are more suitable for denser breast tissue than others," explains Charrin.
The building is also designed to support both digital and film mammography. "Because digital mammography was still being evaluated ... the cancer center wasn't ready to rule out film for this modality. So we put in the plumbing for film processors," Sisolak says.
She adds that the building has very few light boxes since all other modalities are digital or capable of producing a digital image through computed radiography technology, and the center uses scanners to create digital images of referral films. "Where film illuminators were requested, we surface mounted them wherever we could because we knew eventually we'd be pulling them out," says Sisolak.
The center looked to the future in other ways, as well. Sisolak says, "For each modality we planned at least one beta room that was sized a little bit larger, had a little more infrastructure to accommodate the next generation, to allow us to start testing new pieces."
"In some areas we actually recessed the floor and filled that in with a topping slab," says Harris. The topping slab can be removed to accommodate the specific rough-in requirements for future technology.
On the MRI floor, a section of the exterior curtain wall is removable, to make it easier to move equipment in and out of the building by crane. And, says Sisolak, "as we went through the whole design process, we planned specific routes for all the equipment, so there's additional floor loading in places you wouldn't ordinarily expect it because we were either bringing equipment in that direction or we knew that when it came out it would be that direction."
To simplify future renovation, all mechanical systems in the building were placed on outboard curtain walls and data closets, stairs and elevators were kept on the perimeter of the clinical space. With the clinical space uninterrupted by these typical penetrations, it can be more easily remodeled if necessary.
Middle ground
Just as the north and south halves of the building were designed differently to support different weight loads, the east and west halves of the building were designed to separate the patient and staff circulation routes.
Patients and visitors enter the building on the east side. They have their own dedicated elevators, and they move toward the center of the building for appointments. Staff and materials move on the west side of the building.
Gary Owens, AIA, ACHA, associate principal and senior project designer for FKP, says that this layout meant the facility "didn't have any equipment or fast-moving doctors or nurses traveling through lobbies; they had their own corridors to move through." This provides the building with a smooth, efficient traffic flow, he adds.
Color was used to differentiate the staff and public sides of the building in more interesting ways than previously used at the center. Sisolak says, "On our main campus, we used color and pattern to delineate where you were supposed to be or not supposed to be if you were a patient, which turned into some very bland back-of-the-house areas for staff."
The designers took the opposite approach on this project, intensifying color in staff areas. "It's amazing what that little punch of color does to folks' attitude," she says.
Village concept
Improving attitudes was a major concern on this project. Since cancer is inherently stressful, the architects paid great attention to providing a supportive environment for patients, visitors and staff.
This began with KMD's master planning for the expansion project, which centered on the idea of creating a village. The architects studied European villages to determine what made them successful.
"All the historic European villages have a plaza, or green space, for people to gather. That was very important. So we started with that," says Alexander Wu, director of research and strategic planning for KMD.
Having placed the parking underground, the architects were able to use the podium above the parking area as green space. There are large plazas on the second and eighth floors of the building, with plants, shade, seating areas and water features designed to distract and soothe. With their doctor's permission, patients can even receive chemotherapy treatments outside on the eighth floor plaza.
The ACB was designed to provide a variety of experiences, based on input from patients.
Harris says patients told the architects that when they come to the center, "there may be times they're looking for quiet and solitude, there may be times they're looking for nature, there may be times they're looking for interaction." Spaces were designed to meet all these needs. The second floor, in particular, houses a wide array of amenities, including a 200-seat restaurant that features a waterfall.
Care was also taken to provide staff members with gathering spaces of their own. Wu says KMD research revealed that one of nurses' main concerns is a lack of mentoring. Therefore, the building was designed with places "where nurses and doctors can gather to talk and learn from each other," he says.
Natural light was also brought into the building as much as possible, on both the public and staff sides of the facility, to reduce stress and improve working conditions.
Transforming design
Medical advances are transforming cancer treatment and increasing the number of cancer outpatients.
The ACB is designed to allow them to receive their treatments in an environment that meets their physical and emotional needs--and as quickly as possible.
Amy Eagle is a freelance writer based in Homewood, Ill., and a regular contributor to HFM.
PROJECT NAME / University of Texas M.D. Anderson Cancer Center Ambulatory Clinical Building
LOCATION / Houston
OWNER / University of Texas M.D. Anderson Cancer Center
TOTAL FLOOR AREA / 782,000 square feet
NUMBER OF FLOORS / Nine
NUMBER OF EXAM ROOMS / 175
NUMBER OF IMAGING ROOMS / 84
NUMBER OF OPERATING ROOMS / Six
PROJECT COST /$425 million
CONSTRUCTION COST / $230 million
GROUNDBREAKING / July 2001
OPENING / January 2005
To respond to this article, please click here.
Click here for a FREE subscription to Health Facilities Management.
