Design Factors for Behavioral Health Spaces

Standards and guidelines such as the FGI Guidelines for the Design and Construction of Hospitals and Outpatient Facilities are excellent resources to illuminate best practices. As part of a robust and comprehensive patient-safety risk assessment in pre-project planning, it is important to weigh the level of precaution necessary to reduce the risk of patient self-harm.

When designing for Behavioral Health environments, the goal is to accommodate patient safety without negatively impacting the creation of a therapeutic environment conducive to patient healing and recovery.

The purpose of this white paper is to aid the design team by providing resources to assess risks in each space, and select products that deliver on the goals of maximizing treatment outcomes.

The umbrella of mental health (MH) treatment continues expanding to include more conditions needing intervention beyond the traditional diagnoses of neuroses, psychoses and schizophrenia. The broadened definition includes:

• Depression and anxiety
• Bipolar and other brain disorders
• Substance and other addictions
• Eating disorders
• Adolescent issues, including increasing diagnoses on the autism spectrum

In the same way, when considering design of the behavioral health facility, it is important to think beyond only those spaces designed to house the severely mentally ill. As we can see from this list, each category has unique characteristics as to the type of treatment required, and those locations will vary accordingly. To put it plainly, most mental health patients will continue to be treated in outpatient and/or group settings, with inpatient options being employed only for those needing more-direct intervention or protection from themselves and others.

Taking into account the age, mental and physical condition, and treatment course needed of the patients within the space will then impact the risk assessment and the subsequent design decisions made.

Just as occurs within sustainable design and construction planning, a charrette of all the key players can bring to light and work through

• Best practices
• Risks
• Innovative designs that lead to greater healing
• Factors in patient and staff safety

among many others. The charrette should include:

• Owner / Operators
• Risk Assessment Specialist
• Clinicians
• Architects
• Interior Designers

We would add that it's important for Contractors to be brought into the loop – especially in renovation projects – where a patient population may still reside in or utilize other sections of a mental health facility or campus. For example, trade laborers need to keep track of all tools and hardware used, and totally remove all items at the end of each workday so as to remove a potential source of self-harm or harm to others.

An excellent resource for the team is the Behavioral Health Design Guide. It states up front its main emphasis is on the general adult inpatient behavioral health care unit. Updated annually, the Guide offers excellent information and augments regulatory requirements to detail practical means of protecting patients and staff.

One tool within the Guide that we found particularly insightful and helpful is the Hunt/Sine Environmental Safety Risk Assessment, or ESRA (shown on the next page).

The ESRA was designed to facilitate the conversation between clinical staff and designers regarding patient safety. The ESRA matrix considers the opportunity for the patient to be alone in a particular space on the one axis, and a level of risk of self-harm on the other axis.

Level I: Areas where patients are not allowed.

Level II: Areas behind self-closing and self-locking doors where patients are highly supervised and not left alone such as counseling rooms, activity rooms, interview rooms, group rooms as well as corridors that do not contain objects that patients can use for climbing and where staff are regularly present.

Level III: Areas that are not behind self-closing and self-locking doors where patients may spend time with minimal supervision such as lounges, day rooms and corridors where staff are not regularly present. Open nurse stations should be considered under this Level.

Level IV: Areas where patients spend a great deal of time alone with minimal or no supervision, such as patient rooms (semi-private and private) and patient toilets.

Level V: Areas where staff interact with newly admitted patients who present potential unknown risks or where patients may be in highly agitated condition. Due to these conditions, these areas fall outside the parameters of the risk map and require special considerations for patient (and staff) safety. Such areas include seclusion rooms and admission rooms.

We began this white paper with the statement that no product can or should claim to be a "suicide proof" solution. And we would be remiss if we did not also point out that steps like patient suicide-risk assessment and staff supervision are just two operational practices that must factor into an overall suicide-reduction mindset. Another would be limiting access to only those spaces where self-harm risk is reduced – for instance, securing stairwell and roof-top access points.

James Hunt, AIA, has stated that building products can confer a high level of safety without an institutional appearance. "It's the direction all health care needs to go," he says. Hunt is co-founder of Behavioral Healthcare Architectural Group.

With this philosophy in mind, following are several product and system options for a designer's consideration. While these products are designed for behavioral health applications, they do not guarantee patient safety.

Ligature-resistant Handrails – feature a continuous bracket or retainer behind the main rail to deny an attachment point.

Such handrails may be needed in mental health spaces where patients may also need medical care.