To say patient safety is a priority for behavioral healthcare facilities is an understatement. Federal, state and local laws and regulations offer an array of requirements for facilities to meet, but behavioral healthcare organizations also bring their own patient safety standards to the table. New inpatients are often at their most vulnerable, and self-harm protections must be considered. However, experts say design doesn’t have to be hampered by the need for safety.
When America’s Rehab Campuses designs a new facility, the organization is often repurposing a former hotel or resort. From a safety perspective, that means that each new facility brings its own challenges. “We walk through and are prepared to adapt everything,” says Michelle Carrasco, the organization’s chief administrative officer in Tucson, Ariz. That could mean removing a hedge to eliminate hiding places and improve sightlines to patients to removing the materials left behind, like spring mattresses, that could endanger patients if someone removed a spring to use as a weapon. “We bring in fresh eyes—our CEO, chief nursing officer, CFO and our facilities people—to offer opinions on potential changes,” she says.
Carrasco notes that the design focus at America’s Rehab Campuses goes above and beyond legal requirements, for example, by making detox units completely anti-ligature. That means making significant investments to ensure that every element of the design uses anti-ligature products, including air conditioning unit, plumbing and lighting fixtures, hardware, window coverings and so on.
“We spend a lot of money but the detox unit is built specifically for its purpose and that is not inexpensive,” she says.
The fact is, facility design has a tremendous impact on patient safety. It impacts how people move through the building, how much of a given area staff can see at one time and how people feel when they are in specific spaces.
“It is important to live a ‘day in the life’ of a facility and develop an open dialogue about what is going on,” says Mitch Hoefer, founder and CEO of Hoefer Wysocki, an architecture, planning and interior design firm in Kansas City, Mo.
Questions to consider include:
- How does the facility receive patients?
- How does the intake process flow?
- What is the average length of stay?
- What size is the patient population and what are its demographics?
- How much does the patient census fluctuate and does the facility need to accommodate an ebb and flow of patients?
Unique designs for unique treatment
Safety begins well before a patient picks something up and throws it at someone or slips and falls or attempts to self harm. An effective design for a treatment facility can help patients remain calm and minimize opportunities for patients to be destructive or self harm. Bedrooms and bathrooms can be particularly dangerous places for vulnerable patients so keeping patients active and out of their rooms is a common goal.
“To keep patients from lingering in their rooms, you can minimize its sense of place,” says Hoefer. “By providing only the basics, bedrooms become only a place to sleep.”
Other design choices will depend on the unique treatment philosophy of each facility.
“Good designers understand the goals, objectives and principles of a behavioral healthcare practice, its program and its philosophy for providing care,” says Rebecca Sanders, a healthcare principal with design firm HGA in Minneapolis. “Creating a safe environment is one piece of that.”
Designed by architectural firm CannonDesign, the Virginia Treatment Center for Children in Richmond, Va., has built its treatment philosophy around never using mechanical restraints on its patients. To fulfill that goal, the staff and patients need an environment where staff can prevent situations from escalating as much as possible. To that end, the facility has 130 cameras that can be monitored at the nurses station and that staff can turn on using their identification badges. This allows staff members to respond more quickly to emergencies and help avoid dangerous and violent situations.
“Our philosophy is to build a relationship with each child and understand his or her trauma,” says Alexandria Lewis, Ed.D., the facility’s executive director. “We want them and their families to partner with us in their own treatment.”
Making sure the design team understood this philosophy and the facility’s resulting priorities for patient safety was the essential starting point for designing a new facility. She and her team visited similar facilities to see how they approach design and how various design approaches work in a real-life clinical setting. However, they also recognized the need to adjust any safety-related design solutions they saw during these visits to accommodate their treatment philosophy because many of these facilities used mechanical restraints.
“Avoiding mechanical restraints is not a common approach,” she says.
Balance is an important consideration in both design and patient safety. For example, a key part of creating a safe environment for patients is also creating a safe environment for staff. How staff members interact with a space and with patients in that space can have a tremendous impact on patient safety. If staff feel safe and confident that they can handle situations, their actions and decision making are likely to be more effective.
One consideration in design is ensuring that staff can move around a facility safely. That means having clear pathways to leave a room or other area to call for assistance when necessary. It also means having clear sightlines to patient areas and feeling comfortable as they go about their work. For example, one acute care facility created a separate dining area for staff with natural light and clear sightlines and access to the patient dining room.
“It is a place for staff to rest and have respite while still being aware of what is happening in the main dining room,” says Sanders.
By having their own space, staff can relax during a meal without having to interact directly with patients unless it is necessary to do so.
Balance is also needed when designing for everyday activities. Behavioral healthcare organizations may end up designing a facility with a worst-case scenario in mind rather than focusing on the environment they want to create in a given area or for a facility as a whole. Sanders noted that many behavioral healthcare organizations tend of emphasize the durability of materials.
“Their philosophy focuses more on protecting the facility from the patients rather than understanding how the environment can provide dignity for the patient,” she says.
While a focus on protecting against the worst-case scenarios is essential when designing private spaces like bathrooms and bedrooms, behavioral healthcare leaders can reach for middle ground in more communal areas for dining, group activities, recreation and conversation.
“This is where they can think differently about design and not just focus on the worst-case scenario,” says Sanders.
One adolescent treatment facility created a multi-use space for patients that included a pool table, a television, space for reading and playing games and lounge furniture with each area separated by glass surrounds to contain the noise from the various activities while also providing clear sight for the staff. “Everyone needs something different—space for reflection, personal space, community,” says Sanders.
Virginia Treatment Center for Children incorporated abundant natural light and outside spaces into its design to help patients heal from trauma.
“We have a number of courtyard areas that we include in therapy so that children don’t feel that they are being held within a building,” says Lewis. “They can go outside.” The facility design also relies on curves to avoid sharp edges and increase the flow of the layout.
To create these types of spaces that meet patient and staff needs, Sanders suggested that behavioral healthcare leaders set parameters for design. That means evaluating the floor plan to identify the most critical and noncritical areas of the facility, including public areas, and identify materials acceptable for each one with more specific guidelines for bathroom design. Experts agree, there is no one size fits all.
Joanne Sammer is a freelance writer based in New Jersey. Artist renderings courtesy Hoefer Wysocki.