Common Mistakes in Designing Psychiatric Hospitals

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 patients 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 the performance of a safety risk assessment (SRA) for all new construction and major renovation projects. One aspect of the SRA is the 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.

 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 have been formally adopted by many jurisdictions and, in our opinion, are 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, the ratio of activity areas per patient, the number and design of seclusion rooms, the 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.