By: Craig Fredrickson

Continued exploration of the benefits of proton therapy is at the core of the ever-increasing complex construction of new proton centers around the globe.

Proton therapy centers are uniquely complicated large structures typically associated with adjacent medical facilities that can range from $25 million to over $200 million to build, depending on the size and capacity of the facility and equipment. While each new facility is different, one common denominator is the priority placed on the interface between the architecture of the building and the science of the proton equipment. With pieces weighing up to 200 tons, the equipment requirements in a proton therapy facility mandate an attention to detail not always seen in construction projects.



Because of this fact, these miracle-producing medical facilities require complex construction implementation of equally complex designed structures and building systems. Optimal results are greatly enhanced by selecting only the most experienced construction team. Insight and technological integration planning are also critical for a successful project. How quickly and effectively each individual challenge is handled distinguishes the seriously qualified firm from others less able.

Interface management
Due to the complex and dynamic nature of proton therapy construction and infrastructure projects, the ability to identify and classify key activities performed in the field well in advance can improve the quality and reliability of project decision-making and control. Prior experience in the building type – the more the better, coupled with expertise in preconstruction estimating and construction planning are the first steps in predicting success during construction. Managing how specialists interface, whether a waterproofing subcontractor or a nuclear physicist for shielding calculations, cannot be understated.

Equipment and infrastructure interface management
Proton therapy planning does not follow the typical design phases of most capital projects. Typically, the design team outlines the conceptual parameters of the project during schematic design. Subsequent phases are marked by every increasing detail and definition being added to the contract documents, which are then used by the construction team to build. Figuratively speaking, nothing is “cast in stone” until the design is complete and maximum flexibility must be adhered to during construction.

Design and construction teams working on a proton therapy project are faced with an interesting contradiction relative to the more typical process. Critical infrastructure and proton equipment are literally speaking, “cast in stone” from the outset of construction, with no tolerance for deviation. Yet, because of ever-changing technological advances, equipment planned for during design may need modification by the time construction begins. This unique aspect of proton therapy mandates ultimate flexibility during planning and construction for what amounts to absolute inflexible equipment installation tolerances.

Another challenge faced during construction of these types of facilities is general phasing and sequencing. Much of the critical proton therapy infrastructure must be installed prior to more typical building elements. Successfully being able to accomplish this requires collaborative engagement of every participant much earlier than typical. To further complicate matters, participation must include scientists, equipment vendors, physicists and facility operators whose expertise is critical early during design in order for the team to be successful at the end of construction.

One analogy is that typical projects are built from the outside working in while proton therapy projects require the opposite as construction progresses from the inside working out.

Building information modeling (BIM) is an invaluable tool when planning and constructing a proton therapy project. The more typical industry-drawn line separating the design team from the construction team is virtually erased on proton therapy projects. Architects and their consulting engineers work digitally side by side with construction managers and their subcontractors in order to define and achieve the exacting requirements of this project type. Again, the best predictor of success for the project is the collective past experience of the assembled team on similar projects.

Because of the sensitivity of the proton equipment, every item incorporated into the construction must be coordinated relative to adjacency, interface and even chemical makeup. Building system tie-ins are especially critical in this regard. A storm water pipe, an electrical conduit or an embed being a fraction of an inch out of alignment may cause proton equipment failure.

Professional expertise interface
Maintaining allowable construction tolerances on proton therapy projects is critically important for successful operation of the facility. The root of that success is planted during preconstruction by a complex team of cross-discipline professionals, each with their unique perspective and expertise. Creating clear communication protocols within an atmosphere of trusted collaboration is a priority early on that must be leveraged to allow optimal solutions to be individually voiced and then collectively evaluated and approved.

Technology is a tool that has allowed cross-functional collaboration to occur at great distances. Realistically, this new reality is at the same time unavoidable and efficient because whether in Houston or Tokyo, the most experienced team available anywhere must be assembled to create this type of project. Technology enables this global team to be successful. However, technology alone is not enough and some good, old-fashioned, face-to-face conversation is critical. QA/QC planning within these work sessions allows for professional peripheral vision to identify and account for subtle scope gaps between disciplines that otherwise might go unnoticed during design phases.

During construction, the owner, the design team and the construction team continue to work closely together. Because of the fluid aspects of the process described above, quality control is elusive unless monitored and managed continuously during construction. Changes as a result of new equipment development must be accommodated and can only be done successfully by the trusted collaboration established during preconstruction and continued throughout the construction phase.

As a planning tool, lean principles applied to both design and construction phases can play a significant role in delivery of a proton therapy project on time and on budget. Preplanning, pull scheduling and look-ahead tracking can help the team stay on task with critical issues throughout. High-performing, cross-functional teams do not happen by accident and all participants must sincerely participate to be successful. True collaboration is the goal.

Technology, while instrumental for coordination and collaboration as a collaborative tool, must be implemented in conjunction with practical construction knowledge and site awareness. Construction experience in the field must be leveraged in the early design phases of a proton project in order to allow for proper sequencing of field activities. Knowing what to put where and when is only part of the equation. Understanding the long-term ramifications and inter-connected aspects of each component piece of the proton puzzle is imperative for proper operational success. An experienced team is the best insurance an owner can invest in.

With only two dozen or so proton centers operating in the U.S., the need for additional access to proton treatment centers is increasing. Because of the capital investment required to plan, build and operate this type of facility, a comprehensive understanding of the equipment requirements and construction nuances is prudent. The complexities and challenges of installing a massive magnet-packed particle accelerator, fixed beam and isocentric gantry treatment rooms, and the necessary associated supporting infrastructure, including miles of conduit embedded in concrete, all within tolerances measured at unprecedented minimum standards, requires a disciplined approach by all team members.

Successful proton therapy projects share several attributes, including: critical true collaborative participation by all participants; clear, concise communication enabled by technology combined with a team protected environment of professional respect for honest sharing of ideas and information; and most importantly, a team experienced in the nuances and complexities of proton therapy equipment and infrastructure requirements and the knowledge and experience to implement the solutions. In spite of all the latest technologies, nothing can replace construction site experience on past proton projects when it comes to protecting the significant capital investment required.

About the author: Craig Fredrickson joined Linbeck in 1997 and has played an instrumental role in each of Linbeck’s multiple proton therapy projects. Before joining Linbeck, Fredrickson amassed 20 years of health care experience serving as an administrator in both the public and private sectors. This unique professional background allows him to appreciate different perspectives while planning and constructing proton therapy projects for Linbeck’s clients. Fredrickson is a certified health care constructor and is actively involved in the American Hospital Association, American Society of Healthcare Engineers and American College of Healthcare Executives. He is also a member of the U.S. Green Building Council.