Toilet and shower rooms are one the greatest challenges in behavioral healthcare design. Previously, I have written about options for wall finishes in these spaces. Today I want to share my thoughts on planning for toilet rooms.
There was a time when most psychiatric treatment facilities were designed using a barrack-style sleeping arrangement with larger rooms and communal toilets. As the modern world embraced a more compassionate approach to treatment, one of the first adjustments was to push for private or semi-private rooms with private toilets. The obvious benefits to the patient’s dignity don’t require a great deal of explanation, and it was a logical response to the planning approaches of the past. But it is the nature of pendulums to swing, and this issue seems to be moving a bit in the other direction.
It appears that many providers are now considering the idea of communal toilet rooms which are accessed from the corridor instead of from the patient room. A cynical eye would dismiss this as a means of saving money and hold to the idea that private toilet rooms are the best practice as typically required by the Facility Guidelines Institute (FGI) guidelines. There may be truth to that in some cases, but I have engaged with many clients in the last couple of years who are genuinely concerned about safety and functionality.
A toilet room is a safety challenge. Not only is this an inherently unobservable space, but it is ripe with so many opportunities for negative outcomes, even in the best designed space. When that toilet room is accessed directly from a patient room, the risk is increased. The staff have no way to know who is using the toilet room or how long they have been in there. Any unusual sounds or cries (or things breaking) would not be heard by staff outside the room. Nuisance issues such as flooding the room by stuffing a sheet down the toilet are almost impossible to prevent in a private room situation. While the opportunities for negative outcomes exist in a corridor-accessed toilet room, there is a much greater opportunity for staff to recognize an issue earlier and intervene appropriately by checking on the patient or entering the room if necessary, through a key override.
Private toilet rooms are particularly difficult to manage in a semi-private room. The door is a potential ligature point in this situation and most of the typical solutions to that problem infringe on the privacy and dignity of a patient who is sharing a room. Frankly those solutions are problematic even in many private rooms where the bedroom doors lack a privacy function. It is not comfortable to use the toilet behind an unlocked partial door when you know anyone can walk into your room at any time. It is especially uncomfortable when you know your roommate is in the room.
Another functional concern is a simple numbers game. Yes, fewer toilets means less money, but it also means less maintenance. With tight reimbursements, operating budgets are always stretched thin. The more toilet rooms a facility must maintain and keep in safe working order, the greater the chance for an error or a missed correction creating the opportunity for a patient to self-harm.
I continue to be a believer in private toilets and private rooms as an idealized best practice. In long-term or step-down units, this should, in my opinion, still be the first choice. However, in acute care or crisis stabilization facilities, there is a strong logic to planning around shared toilet rooms. The FGI guidelines acknowledge this when they require private toilet rooms except “where the use of corridor access is part of the hospital’s written clinical risk assessment and management program.” In other words, it is not OK to do this to save money, but it is OK if your goal is to create a safer, more viable program tailored to a specific patient type.