A successful design
for a psychiatric hospital requires careful coordination of a multitude of
factors; there is no one-size-fits-all solution. The final design will be
unique to the individual facility and its stated goals and philosophies. In
particular, many elements typically used in general hospitals to address the
specific needs of patients and staff are needlessly carried over into
behavioral health facilities, even though the functions they are intended to
address are not present or needed in psychiatric units.
Some organizations
state they have a very low tolerance for risk and want the safest possible
environment for their patients. Other organizations, desiring a more home-like
ambience, require upgraded finishes that appeal to a different aesthetic. These
two approaches can lead to very different design solutions. Most hospitals fall
somewhere between the two extremes.
Other basic
differences between organizations that can affect their design goals are their
funding source (public or private) and organizational structure (not-for-profit
or for-profit). Other variables that influence key components of the final
design are patients’ average length of stay, diagnoses, acuity, age, and
co-existing medical conditions and whether they are voluntary admissions or
committed by the court.
Suicide prevention
and other patient and staff safety issues in psychiatric treatment units
present a unique set of issues for the designer. In the six years since this
paper was first published, we have continued to visit newly constructed
facilities that have serious design mistakes that must be corrected before
patients can be admitted.
Unique in our
experience was a request from one of these visits from the hospital’s insurance
company. We found it interesting that the insurance company recognized there
were problems with this facility although the design architects were confident
their design was safe. Other facilities have spent substantial amounts of money
remodeling existing units with changes that not only did not resolve patient
and staff safety issues, but in some cases actually made the units less safe.
Provision
of a Therapeutic Environment
A therapeutic
environment can be defined as a patient care environment that helps make
patients more receptive to the treatment provided by staff. Some who provide
services to psychiatric patients feel the built environment where these
patients receive services should resemble a “typical residential” atmosphere.
Unfortunately, patients from different backgrounds may have entirely different
views of what constitutes a home-like setting.
A more realistic
goal, then, should be to create a non-threatening environment in which patients
can feel relaxed and comfortable. To achieve this, architects must work closely
with hospital staff, patient groups, interior designers, and psychiatric
hospital consultants and refer to the Guidelines for Design and Construction of
Hospitals and Outpatient Facilities (Facility Guidelines Institute 2014) to
find the right mix of elements that will create this atmosphere. The mix will
likely be different for each hospital and sometimes units within a facility may
have different requirements, although for safety reasons each individual unit
should have uniform features.
As previously stated,
many elements and items typically provided in general hospitals to address the
needs of patients and staff are carried over into behavioral health facilities
even though those functions are not needed for the services provided in
psychiatric units and may, in fact, be contrary to safe design.
For example, lighting
with 2'x4' fluorescent fixtures, commonly used in general hospitals, does not
provide a residential feel and replacing such fixtures with round or oval
vandal-resistant fixtures or vandal-resistant wall sconces can simultaneously
improve safety and make a big difference in the character of a facility. As
well, paddle-style door hardware, which is intended to help staff open doors
with their hands full, is rarely seen outside of hospitals and is generally not
necessary in behavioral health facilities. The Design Guide for the Built
Environment of Behavioral Health Facilities (Hunt/Sine 2015), co-authored by
us, contains references to several types of light fixtures and door hardware
that offer a higher level of safety for both patients and staff in behavioral
health facilities.
These are but two
examples of many general hospital elements that are not desirable for use in
typical behavioral health units. Providing them unnecessarily reinforces the
institutional character of such facilities, may needlessly increase cost, and
may actually lessen safety in the built environment. Other general hospital
elements, such as medical gas outlets, bedpan washers, nurse call systems,
light fixtures located directly over the bed to enable staff to perform medical
procedures, and wrist handles on faucet valves, are simply not needed in a
psychiatric unit. At the very least, when designing behavioral health units,
attention should be paid to the following principles:
• Use of color, texture, and natural
materials such as transparent wood finishes can provide a more residential
feel.
• Lighting must limit patient access to
the bulbs, and thus to their glass and electrical contacts. Table lamps are
very difficult to do well and should generally be avoided.
• Soft, upholstered furniture with wood
accents that is constructed to withstand severe abuse can be anchored in place
to avoid stacking or throwing.
• Bathrooms must be designed with
safety in mind, and compromises in these rooms can have disastrous results.
The typical code
issues of lighted exit signs, fire sprinklers, fire extinguishers, and so on
must be provided, even though they may contribute to a facility’s institutional
appearance.
Patient
and Staff Safety Concerns
In the Design Guide,
we state that “no built environment—no matter how well designed and
constructed—can be relied on as an absolute preventive measure. Staff awareness
of their environment, the latent risks of that environment, and the behavioral
characteristics and needs of the patients served in that environment is an
absolute necessity.” Preventing a patient who has made up his or her mind
to commit suicide
from succeeding may require the use of constant physical or chemical
restraints, and that is not treatment. Providing these patents with treatment
and the opportunity to improve involves taking risks. The facility staff and
the design team must determine what degree of risk is acceptable and
appropriate for a particular facility and patient population.
Many standard
protocols for behavioral health facilities rely heavily on patient scores on a
suicide risk assessment tool. The staff may use this score to assign a patient
to a room located near the nurse station or to put a patient on “suicide
precautions” such as 15-minute checks or one-on-one observation. However,
dependence on these assessment tools has two problems:
1. Numerous studies have concluded that
the suicide risk assessment tools currently available are not reliable. (Haney
2012, Tishler and Reiss 2009, Milone 2001, Simon 2006a, Simon 2006b)
2. Measures typically used to mitigate the
risk of self-harm, such as 15-minute checks and moving “suicidal” patients into
specially equipped rooms near the nurse station, have not been proven effective
in preventing suicides. The Joint Commission has documented that the average
number of inpatient suicides reported to them as sentinel events over the
10-year period 2004 to 2013 ( Joint Commission 2014) was 77.5 per year. The
numbers for 2012 and 2013 were 85 and 90, respectively. Clearly, this problem
has not been solved and suicide frequency is again on the rise.
Once staff and the
design team have determined the overall level of risk tolerance for a
psychiatric hospital or nursing unit, the next step is to assess the acceptable
level of risk for each patient-accessible area. The level of risk from the
built environment that is acceptable in a group room where staff members are
always present is different from that in a room where patients will be alone
for long periods, such as bedrooms or bathrooms.
The 2014 edition of
the FGI Guidelines requires performance of a safety risk assessment (SRA) for
all new construction and major renovation projects. One aspect of the SRA is
identification of areas that will serve patients “at risk of mental health
injury and suicide.” For these at-risk locations, the SRA team must identify
“mitigating features” and include them in the SRA report. This requirement
appears in Section 1.2–3.6, Behavioral and Mental Health (Psychiatric Patient
Injury and Suicide Prevention), which also specifies that “behavioral and
mental health patient care settings
It shall be designed
to protect the privacy, dignity, and health of patients and address the
potential risks related to patient elopement and harm to self, to others, and
to the environment. The design of behavioral/mental health patient areas shall
accommodate the need for clinical and security resources.”
The appendix to
Section 1.2–3.6 discusses the “behavioral and mental health risk assessment,”
but because this text appears in the appendix it is presented as a recommended
practice rather than a requirement. Reference is made to the Design Guide for
further information about risk assessments.
The conversation
between clinical staff and designers about patient safety can be facilitated by
using a patient safety risk assessment matrix that considers the opportunity
for a patient to be alone in a particular space (of any type) on one axis and
the level of risk of self- harm by the patient on the other axis. The greater
the opportunity for a patient to be alone, the greater the opportunity for
self-harm and the more caution that should be taken regarding design choices
and materials. Because patient intent for self-harm is often opaque and
difficult to assess, it is preferable to weight decisions toward the high end
of the scale.
Hunt/Sin
Programming
As with all projects, a successful
design begins with a comprehensive functional program. Typical information
obtained from the client includes the number of beds, number of offices, and so
on. In addition, we highly recommend careful consideration of the requirements
in the FGI Guidelines. The Guidelines has been formally adopted by many
jurisdictions and, in our opinion, is the established standard of care for the
design of health care facilities.
It is not uncommon to encounter resistance
from clients who do not want to provide seclusion rooms that meet the
Guidelines requirements or do not want to allow for as much activity space as
required. However, compliance with the parameters outlined in this document may
provide a lower level of legal exposure for the institution and the designer if
the design should ever need to be defended in a court of law.
Therefore, we recommend that the size
of the patient rooms, ratio of activity areas per patient, number and design of
seclusion rooms, location and number of patient toilets and bathing facilities,
and other features be provided as prescribed in the FGI Guidelines. If the
client insists on varying from these standards, these deviations and the
reasons for them should be clearly documented and concurrence sought from the
appropriate authority having jurisdiction.
Source ; FGI Guidelines