This article originally appeared in the Journal of Healthcare Protection Management in August 2013.
With the closing of many large state-run behavioral healthcare facilities in many areas of the country, more patients with behavioral health needs are being managed locally. This often means shorter in-patient stays, more outpatient treatment, and patients presenting in your Emergency Department for triage and treatment.
Greater reliance on local care may provide a more personalized setting, but many healthcare facilities are often not equipped to handle the range of challenges that treating patients with behavioral health diagnosis can present. With increased patient care load, healthcare managers are seeking additional space to meet these care needs. Sometimes patient space is retrofitted from previously used behavioral healthcare treatment areas that may have been set up as wards or shared sleeping settings. Sometimes behavioral healthcare treatment areas are carved out of existing general care patient rooms.
Regardless of its previous use, the challenge is to retrofit the space in a way that contributes to the best possible care and outcomes for behavioral health patients while still providing appropriate risk management for both the patients and your staff. What should be your first steps in assuring that your facility treats patients with the best possible care while preventing as many risks as possible?
First Step: Understand Your Patient Needs and Treatment Models – It’s Not One-Size-Fits-All
According to an article in Behavioral Healthcare (Design Mistakes, Part 1: Things Many ‘Know’ That ‘Just Ain’t So’ December 3, 2012) by James M. Hunt, AIA, NCARB, 1 there is a “flawed assumption of similarity.” The article states that models such as “house/neighborhood/downtown” do not adequately account for patients who are only on the unit for short stays and may not have time to progress through the stages that this model embraces.
So the first consideration before any design begins should be to ask: who is your typical patient? How long does the average patient stay? What are typical treatment plans and acuity levels? What is the staffing and organizational structure?
A team of behavioral health professionals should clarify and define your patient population and treatment needs. Once you have a clear understanding of your model, spaces can be designed that actually meet your specific requirements.
Don’t rely on a “best practices model”; your facility may be treating patients who are staying shorter or longer than the model, may have different treatment needs.
Current trends are just that – trends. Resist the herd mentality and be willing to adopt parts of different models if they work best for your patient population.
Regardless of which design model you follow, incorporate some of these elements into your design plan to enhance patient environments: natural light, views of green spaces if possible, acoustical sound insulation and privacy, non-institutional materials, good signage and “way finding”, durable and attractive finishes, access to controlled outdoor space, and a balance of visual privacy and safe observation.
Second Step: Risk Assessment – Keeping Patients and Staff Safe
Once you have a comprehensive patient profile and treatment study in place, and before you commit to a final design, it’s time to understand the visible and hidden risks in any facility. Risk falls into two basic areas: risk of harm to the patient and risk of harm to your staff.
Risk of Harm to Patient:
According to the Veterans Administration (Haney and O’Neil, 2012)2 suicide assessment tools do not accurately predict risk. A study by the American Psychiatric Association (2003) backs this up: 2/3 of patients who actually commit suicide were never identified as being at-risk.
You need to consider all patients as being at risk for suicide.
The facility itself can only do part of the job. Staff vigilance and training is just as important towards keeping the patients safe A report by National Institute of Health (Suicide in the Medical Setting, Ballard, Pao, et al, 2009)3 looked at the most common methods of suicide in a psychiatric setting. Jumping accounted for 26.4% of deaths, hanging accounted for 22.7%, drowning 13.9%, poisoning 12.4%, cutting 1.6% , firearms 3.0% and other 20.1% accounted for the rest.
Knowing these statistical risks, you can assess your facility.
Jumping: Look at all areas with an eye toward preventing access.
- Are windows secured?
- Is every screw tamperproof?
- Is patient access to any roof area blocked and/or alarmed?
- Are there any balconies or courtyards that are a danger for climbing?
- Tall furniture should not be permitted in patient areas.
Strangulation: Focus on points of attachment.
- Shower or curtain rod, it should break with 40 pounds or less pressure.
- Plumbing should be assessed to assure that there are no attachment points such as pipes, showerheads, or faucets.
- Furniture should be firmly bolted to walls and have no attachment points.
- Ceilings should have smooth surfaces; no ceiling tiles or grids.
- Fire suppression sprinkler heads should be tamper-proof and where possible, recessed into the ceiling.
- Door hardware should prevent ligature attachment; special alarms can be installed to detect the pressure of a ligature at the top of the door, and piano style hinges should be standard.
- Cords from patient call systems, telephones, or electrical should be inaccessible by the patient. Any exposed cords should be no more than 6 inches long. Move the tamperproof outlets closer to where they are needed; eliminate any outlets that are not absolutely necessary.
Drowning: Is there any type of standing water? Are there bath tubs or therapy tubs in patient treatment areas or as part of a treatment plan? These areas should be kept locked.
Poisoning: While most facilities strictly regulate and control their medication management, additional vigilance must be taken around patients. Cleaning supplies and chemicals must be secured both on carts and in closets. Hand sanitizers should not be wall mounted in any patient areas; staff should maintain direct control of this material.
General risks: Mirrors must be made of shatterproof materials. Window treatments should be minimized, with no cords or lengths of fabric.
Risk of Harm to Staff:
You need to balance patient needs for privacy with staff safety. While many patients do not want windows in their doors and consider it an invasion of privacy, staff should be able to observe patients at all times before entering the room.
It is also vitally important that patients cannot fashion weapons out of anything including peeling laminate, furniture, glass, or dinnerware. On locked units, every staff member should carry the key or keys at all times that would be used in case of any emergency.
One ofthe best resources written to evaluate your facility is the Mental Health Environment of Care Checklist 4 published by the Veterans administration and is readily available on the VA website as a downloadable Microsoft Excel spreadsheet. For both patients and staff, it is vital to have a plan in place, clearly spelling out the reasons for action items. Everyone must agree and follow all items for patients and staff to stay safe.
Understand Your Needs: Taking the time to thoroughly define your patient profile and your methods of care will create a more thoughtful design process. Look at accepted practices and design methodologies with a critical eye. While parts of the methodology may mean a better patient experience, you and your patients are not “one size fits all.”
Assess and minimize risk: View any behavioral healthcare patient areas through the lens of protecting patients and staff. Understand the most common risks of patient self-harm and constantly monitor to make sure that any procedures are followed at all times. The key to success for this process is for both sides of the team – clinical and facility – to be willing to step forward and trust the opinions of all members. Members must have a specific, actionable plan, and be willing to follow all points. This can assure that you have patient spaces that work as both a place of excellent care and safety for patients and staff.
1 – Design Mistakes, Part 1: Things Many ‘Know’ That ‘Just Ain’t So’, James M. Hunt, AIA, NCARB, Behavioral Health Care, December 2012, Link: http://www.behavioral.net/article/design-mistakes-part-1-things-many-know-just-ain-t-so
2 – Suicide Risk Factors and Risk Assessment Tools: A Systematic Review Principal Investigators: Elizabeth M Haney, M.D., Maya Elin O’Neil, Ph.D., M.S. Published: Veterans Administration, 2012 Link: http://www.hsrd.research.va.gov/publications/esp/suicide-risk-REPORT.pdf
3 – Suicide in the Medical Setting, Elizabeth D. Ballard, Maryland Pao, M.D., David Henderson, M.D., Laura M. Lee, B.S.N, J. Michael Bostwick, M.D., and Donald L. Rosenstein, M.D. , Published: National Institute of Health, 2008, NIHMSID: NIHMS104618 Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2680547/
4 – Mental Health Environment of Care Checklist, Veterans Administration (Microsoft Excel spreadsheet) Link: http://www.patientsafety.gov/SafetyTopics/MHEOCC.xls