Cranes, bulldozers, and a corps of construction workers have swarmed onto the Duke University Medical Center campus, signaling the start of an ambitious expansion project designed to dramatically enhance the experience of patients, families, students, and staff at Duke for decades to come.

Following rigorous rounds of project reviews and approval by the State of North Carolina, Duke Medicine leaders announced in August 2009 their decision to move ahead with the historic initiative, which has been on the drawing board for several years.

"Duke Medicine is all about people -- it's about the patients we serve, it's about the people who work here to deliver the best care, discover new things, and train the next generation," says Victor J. Dzau, MD, chancellor for health affairs.

"To support those people in the years to come, we must make sure that we have the state-of-the-art facilities we need to provide the best care and the best environment to work and learn in."

This vision is now becoming a reality with the official start of two landmark buildings. Together, the new Duke Cancer Center and the Duke Medicine Pavilion, along with related renovations, will add more than 800,000 square feet of space, with 160 intensive- and intermediate-care inpatient rooms, 16 new operating suites, 130 exam rooms and 75 infusion spaces dedicated to cancer care, and expanded and updated imaging platforms. Total project costs are estimated at more than $700 million.

Planning is also under way for a new School of Medicine learning center that will provide an optimal environment for medical student and interdisciplinary team training. The larger, modernized facilities are greatly needed not only to accommodate an increasing demand for patient care, but also to support the broader vision for medicine at Duke, according to administrators.

The new facilities are thoughtfully designed to:

• Improve the patient experience by making clinic visits more efficient, increasing inpatient room size, better accommodating visitors and family members, and providing amenities such as resource centers, healing and spiritual spaces, and green spaces
• Support multidisciplinary care by co-locating a wide range of providers within fast-growing specialty services such as cancer and heart
• Accommodate leading-edge clinical technologies including advanced imaging and diagnostic equipment and linear accelerators for cancer radiation therapy
• Enhance education and research by providing state-of-the-art facilities that support training, facilitate study of new techniques and treatments, and bring clinical research teams closer to patients
• Incorporate advances in information technology to improve communications between clinical teams and individual patients -- not only within each building, but across the continuum of Duke Medicine services and sites

Although the global economic crash in 2008 diminished Duke’s capital reserves,
Duke Medicine leaders remained committed to moving ahead -- describing the efforts as a mission-critical investment in the future.

"Without expansion and modernization, the quality of our patient care could suffer and our long-term goals could be significantly stunted," Dzau says.

"Years of conservative and prudent fiscal management, combined with careful cost-cutting measures, have put us in a strong position to move forward with these projects -- which we believe are essential to our ongoing ability to meet the growing demand for patient care services and to conduct cutting-edge research and training in an era of population growth and accelerating innovation.

"At heart, we believe we have a responsibility to meet our patients' needs for high-quality health care in the years ahead."

In addition to institutional investment, fund-raising initiatives have been launched to raise $75 million toward the costs of the Duke Cancer Center, $50 million toward Duke Medicine Pavilion, and $15 million toward the learning center, which is also supported by a $35-million gift from The Duke Endowment.

"The vision for the future of the campus is to continue to support what makes
Duke Duke: excellence in clinical care, teaching the next generation of all kinds of providers, and generating innovations that we can push through the enterprise," says Kevin Sowers, RN, MSN, CEO of Duke University Hospital.

"It's about supporting incredible people who work here every day and do incredible things in people’s lives, by giving them facilities designed to enhance their efforts to care for Duke's surrounding communities, the residents of North Carolina, and beyond."

Training Spaces

Besides serving hundreds of thousands of patients every year, Duke University Medical Center is also home base for one of the country’s largest health-care training programs, with more than 900 medical residents and fellows on the house staff, plus more than a thousand students in the medical, nursing, physical therapy, and physician assistant programs. The planned campus expansion will benefit these next-generation caregivers as well as the patients they’ll serve:

• State-of-the-art technology from new linear accelerators in the cancer center to interoperative imaging technologies in Duke Medicine Pavilion’s surgical platform will allow clinicians to better practice -- and therefore teach -- to their full potential, facilitate research that will improve care and support training of academic physicians, and enable trainees to gain experience in cutting-edge care.
• A School of Medicine learning center located in the heart of the medical center campus -- the first new building dedicated to medical education since 1930 -- is being planned to provide the team-oriented, technology-based experiences today’s curriculum demands. “New learning space for our students was the top priority for our own leadership and the main recommendation during our recent accreditation process,” says Dean Nancy Andrews, MD, PhD. “Medical education has changed dramatically since our current facilities were built. The vision for this new space is to provide our students with the laboratories and training facilities that will best help them prepare for their future careers.”

The new buildings have been preceded by new facilities for the School of Nursing (completed 2006) and the physician assistant program, which in early 2009 moved into a freshly renovated building designed to accommodate future growth.

Read more about the planned learning center in  the summer 2009 issue of DukeMed Alumni News, online at medalum.mc.duke.edu.

Duke Medicine Pavilion: Answering Demand for Surgical and Intensive-Care Services

Since its current bed tower opened in 1980, Duke University Hospital has grown not only in patient volume but also in reputation as one of the most advanced hospitals in the country. And frankly its success has the 29-year-old building bursting at the seams.

From Monday through Friday, the hospital fills at least 90 percent of its 924 inpatient beds, many of them with critically ill patients sent here for the best medicine has to offer.

A 2005 study showed Duke's OR usage to be 93 percent -- compared to 80 percent for the average academic medical center. And with every upgrade to new technology, Duke electricians and IT experts have to figure out how to rearrange the guts of the building to support the state-of-the art tools in play.

The plans for the new Duke Medicine Pavilion -- a 580,000-square-foot addition to the hospital housing OR suites, intensive care units, step-down units, and diagnostic facilities -- have focused on maximizing flexibility of space and technology, leaving Duke Medicine room to grow.

Operating Space

The 16 new OR suites will be larger than the current operating rooms in order to accommodate advances in technology that enhance precision and safety. The new suites are designed to be flexible, allowing both multipurpose and specialized use: interoperative MRI and CT are located between suites, for instant access that won’t crowd the room when not in use.

A hybrid OR is already under construction in the current hospital, and will open in 2010; it will allow interventional cardiologists and surgeons on-the-spot, highly detailed vascular imaging capabilities -- and enable easy transition between catheter-based, minimally invasive, and open procedures within the same space.

Built-in technology will enable the surgical team to review critical information without going to multiple places or even stepping away from the table: multiple plasma screens will allow surgeons to review x-rays and other imaging studies, as well as pathology specimens.

"Duke’s surgical faculty are nationally and in many cases internationally respected, and demand for their services is exhausting our current facility," says Danny Jacobs, MD, MPH, chair of the Department of Surgery.

"The Duke Medicine Pavilion will be critically important to our ability to meet surgical demand and train the next generation of surgical leaders."

Roomier Rooms

Duke Medicine Pavilion’s 96 critical-care and 64 intermediate-care beds won’t just add more space, but better space -- reflecting dramatic changes in care since the hospital’s Anlyan bed tower was built.

Then, patients arrived for surgery the night before the procedure; their families awaited results in the waiting rooms and sat with their loved ones in brief stints during visiting hours. Today families want to stay with patients around the clock, and the new patient rooms are designed to accommodate more people -- clinicians and family alike.

These and other features of Duke Medicine Pavilion reflect input from current patients, families, physicians, nurses, and other staff, says Mary Ann Fuchs, RN, Duke University Health System's chief nursing officer.

"The building’s entire layout will allow patients much more access to their families, allow the staff more interaction with patients, and allow the staff to work in a more streamlined fashion. We strove to create a place where multidisciplinary teams could work well together and where patients could feel comfortable and cared-for."

High-Tech Hospital

In addition to upgrades in the OR, a high-tech, centrally located imaging center will streamline access to MRI, CT, and nuclear testing for patients and clinicians. The building will also accommodate new tracking and electronic medical record (EMR) technology, enabling better coordination of care within the hospital, across the health system, and beyond Duke.

"Most medical errors and patient safety issues emerge when a patient transitions from a hospital to a primary care setting," says Asif Ahmad, chief information officer for the health system.

"Our EMR technology already coordinates a patient’s information among all three of our hospitals; our plan for this building is to go ‘EMR-plus’—to use technology to improve patient education and help prevent glitches in the translation of information when they leave the hospital."

Patients -- and Providers -- in Motion

The layout of the hospital -- as well as the cancer center -- began with studying all the traffic that flows through current service areas, from shift changes to patient transport.

For example, neurology patients have to go for CT scans frequently, so designers worked to locate the neurology ICU near CT. And all heart services throughout Duke University Hospital will be located on the same level, regardless of what building they are in.

A two-story concourse -- just about the same width as an airport concourse -- will be the "Main Street" that connects Duke Clinic to Anlyan Tower. The totally enclosed and climate-controlled concourse will simplify the journeys of patients and staff as they move around the medical center.

Healthful and Healing Spaces

Great care is being taken to create an environment that is pleasant and supportive for patients and their families. A major component of that philosophy is linking patients to the world beyond the facility walls -- by providing green spaces that can be seen from patient rooms and waiting rooms alike.

The Duke Medicine Quadrangle: The doors of the cancer center and the new hospital addition will open onto a park designed by Laurie Olan, the landscape architect who redesigned both Columbus Circle in New York City and Philadelphia’s Independence National Historic Park. Similarly designed courtyards within the hospital will provide more green views for patient rooms.

Patient resources: The main doors of the hospital addition will open into a two-story entryway that leads visitors to a patient library, a café, and a quiet meditation or reflection space.

Letting the sunshine in: The overall facility design brings natural light into staff and patient-care areas. "That actually is really helpful to patient and staff morale," says Fuchs, "just having a pleasant environment in which to do our work."

Green in more ways than one: Besides its visual connection to the outdoors,
Duke Medicine Pavilion -- targeted for LEED Silver status -- is designed to be environmentally friendly, with green roof space, sustainable building materials, and energy-efficient mechanical systems.

Duke Cancer Center: Creating the Optimal Experience for Cancer Patients

When Harry Rhoads was diagnosed with stage 4 melanoma three years ago, his Duke oncologist told Rhoads he most likely had about 11 months to live -- but that he could join a clinical trial of a promising new interleukin drug.

The treatment schedule would be difficult: two weeks of treatment and two weeks off, for a total of six treatments. Each round of interleukin was followed by "six days of hell," Rhoads says -- nausea, vomiting, hallucinations.

"I was scared."

But PET scans showed that the tumors were shrinking with each session. Despite a few setbacks, Rhoads is cancer-free today.

Rhoads’s experience of cancer treatment isn’t representative of all cancer patients; as every tumor type is unique, every cancer patient has his or her own treatment experience. But in many ways, Rhoads says, "every patient goes through the same thing" -- a complex balancing act of fear and faith, suffering and grace.

Rhoads lives near Washington, DC, so his choosing Duke for his treatment went beyond the considerations of distance and convenience.

William J. Fulkerson Jr., MD, Duke Medicine’s senior vice president for clinical affairs, says patients like Rhoads travel to Duke for access to world-class specialists and the promise of the newest and most comprehensive treatments for the disease that threatens their lives.

As one of only 40 National Cancer Institute-designated Comprehensive Cancer Centers in the nation, Duke offers options that simply aren’t available in many hospitals.

"There are two things that set academic medical centers like Duke apart from other health care organizations," says Fulkerson. "One is that highly focused specialists from many disciplines work together under one roof to provide comprehensive care; the other is that academic medical centers are in the business of bringing innovation to the table as quickly as possible."

The impetus for building Duke Medicine’s new cancer center facility, say its leaders, is to continue to deliver on that promise to an ever-growing number of patients. By more closely integrating clinician and clinical research teams, the design of the building seeks to promote the best of academic medicine’s multidisciplinary and research-driven nature.

In addition, the space must provide the most healing, patient-centered environment possible to support patients like Rhoads as they go through the journey of fighting, living with, and surviving cancer.

Combining these mandates of form and function is a tall order -- and that's why the vision for the project goes far beyond adding square footage. In fact, leaders say, the goal is nothing less than to create the best possible cancer treatment experience.

What Makes "Multi-D" Work?

A key part of that is enhancing the multidisciplinary approach that distinguishes cancer care at Duke -- and that studies show is associated with better patient outcomes. But the buzzword multidisciplinary has multiple meanings.

Depending on the cancer type, multidisciplinary care at Duke might mean having different specialists working in the same space on parallel schedules for easy "collaboration on the fly," or it might mean scheduling clinicians around each patient -- such as in the Duke Prostate Center, in which a newly diagnosed patient is visited by a surgeon, radiation oncologist, and medical oncologist who confer with each other to develop a coordinated, comprehensive care plan.

And then there is the expertise of specialized nurses, nutritionists, psychologists, social workers, and physical therapists, all of whom work in concert to provide Duke cancer patients with whole-person care.

If the fuel that powers these many modes of multidisciplinary care is the talent pool of the clinicians on staff, then the rate-limiting factor is space -- which in Duke’s current buildings is growing tighter due to swelling patient volume and the continual introduction of new and better imaging and radiotherapy technology.

This is why the most talked-about feature of the new building is space: 267,000 square feet of it, including ample room to bring clinicians, counselors, and research staff from their current far-flung locations into dedicated space closer to patient exam rooms.

"Physicians want their patients to have multidisciplinary care that doesn’t require coming to Duke three or four times to see different doctors," says Carolyn Carpenter, the health system’s associate vice president for oncology services.

"Adding space to our facility will allow us to schedule patients and clinicians in a way that's more efficient -- and that will lead to a better experience for the patient."

Designed to Heal

Not only the exam rooms but the entire building is designed to deliver an ideal patient experience. Planners began by mapping out all the stops cancer patients have to make during a visit to Duke, from registration and the pharmacy to mammography, MRI, labs, chemotherapy, or radiation therapy.

"Then we went to focus groups [of Duke cancer patients] and said, 'Here’s what we think the experience is like. Do we have it right? And what would you change?'" says Sowers.

The central premise behind every focus group -- and there were several -- was how to make cancer care revolve around the patient instead of the patient's disease.

In the case of radiology, for example, patients didn’t want to have to walk to one part of the building to get a CT and then another to get an MRI, as they do in the current facility; in the new building a full floor of the cancer center hosts all of the radiology platforms in one consolidated area.

When patients enter the new building, they'll be welcomed by a resource center -- no long registration queues or full waiting rooms in sight. The boutique, food court, and outdoor spaces are designed to provide pleasant options for patients who are waiting before or between appointments.

And the waiting areas themselves are designed to accommodate comfortably both the patients and the family members who travel with them.

"We did studies of how many people typically accompany a clinic patient and an infusion patient," says Carpenter. "And we used that information to determine how big our waiting areas should be."

Betty Lamar, a member of Duke Cancer Institute’s Citizens Advisory Council, says the intangible effects of a patient-friendly atmosphere make all the difference -- and she should know. Her first husband died of leukemia, while her second had bladder cancer, and she experienced the full spectrum of cancer care in a variety of clinical settings.

As a veteran caregiver, Lamar says she’s seen how cancer treatment has shifted over the years to a patient focus.

"At Duke they are now really treating the whole person and not the disease," she says. "It didn’t use to be like that, it was all focused on the disease."

Lamar serves as a volunteer at Caring House, a home away from home for many Duke cancer patients. She says she has seen many patients and families who reflected her own experience.

"They would arrive so afraid and anxious," she says. "They came from all over the country and world. They were desperate for help."

Room to Advance

The draw for these patients is often the clinical trials offered at Duke, such as the interleukin trial Rhoads is part of. In fact, Duke is currently conducting more than 700 cancer trials.

"Cancer care, almost more than anything else that we do at Duke Medicine, is a fast-evolving field -- new treatments and new understandings emerge all the time," says Fulkerson.

Clinical trials are what drive these discoveries into cancer care practice, and the studies are "fundamentally intertwined with clinical care," says breast oncologist P. Kelly Marcom, MD.

"We need efficient clinical space to ensure a seamless approach to clinical research, as well as patient care. With the new building, we will have additional space to educate patients about clinical trials and accrue individuals to participate in these trials."

The new building will include dedicated space for clinical trial consultation and coordination, making standard what was previously a rare luxury for clinical trial coordinators -- complete privacy and uninterrupted quiet space near patient exam rooms to discuss clinical trials, informed consent, and any questions a patient has about clinical research.

Also, says radiation oncologist and Duke oncology services medical director Christopher Willett, MD, the new building will house brand-new, first-in-world imaging and radiotherapy technologies that will supplement both patient care and research.

"In addition to expanding the space and bringing in more tools, we are intensifying our focus on the patient’s experience. The new building will be more efficient for them and for us -- and very user-friendly. I think that all of us feel extraordinarily positive about the plans for it."

Lamar made the first gift to the Cancer Center building fund, which Duke hopes will raise $75 million toward the project’s estimated $220-million cost.

"Where you're treated is a very important part of treatment and cure -- it's important to be in a happy place," she says. "And the new building will really make you feel that way.

"It’s a place that makes you realize that you’re being considered as a whole person."

This article was first published in the Fall 2009 edition of DukeMed Magazine.