Key Considerations for Behavioral Health Inpatient Unit Design

Behavioral Health, often used interchangeably with Psychiatric Health or Mental Health, is a healthcare field that has experienced increasing demand in recent years. It recognizes a connection between our behaviors and the health and well-being of the body, mind and spirit. This includes behaviors such as eating habits, drinking or exercising that either immediately or over time impact physical or mental health. It can also include factors such as depression, anxiety, or substance abuse.  

Being curious and seeing a learning opportunity, I asked our client, SSM Senior Project Manager Jenny Nelson about some of the challenges faced in design and construction of the project. What I learned was that Jenny has a wealth of knowledge when it comes to Behavioral Health constructability and operations. Through a tour of the new unit we talked about the behavioral healthcare climate and discussed insights gained during the project some of which are shared here today. 

Behavioral Health Pressures for Healthcare Systems

Behavioral health services are on the rise largely due to increased access to healthcare. The Affordable Care Act and The Mental Health Parity and Addiction Equity Act have improved insurance coverage for behavioral health and increased patient volume. Substance abuse fueled by the opioid crisis has also contributed to the growing demand for behavioral health needs. 

Health systems are adapting to the increasing patient volume with changes to their facilities by adding more residential treatment beds, increased outpatient visits and renovating their hospitals to be better prepared to receive these patients.  A majority of these patients arrive through the Emergency department and have a longer length of stay in an inpatient nursing unit.  As a result, these are the more common areas to receive upgrades for behavioral health patients.

What Makes Behavioral Health Environments Unique?

Behavioral health spaces differ from the typical healthcare spaces we design. Unfortunately, suicide is a major concern, so they must be designed to prevent patients from self-harm. All patient areas must be designed with great care to not create any opportunities for a ligature attachment or features allowing patients to hurt themselves in some other way. This requires scrutiny of every product chosen and every detail built in patient areas. Furniture, tamper proof switches and outlet plates, doors, hinges, knobs, faucets, shower controls, windows, very high impact drywall and pick proof caulk are among the long list of specialty products needed for every treatment space. 

With all the technical attention in behavioral health design it is important to also consider the patient experience in these projects. Natural light and views outdoors should be maximized to provide a comfortable environment. Open plans should be used to create a spacious feeling for those needing care.  Trends in inpatient unit design include strategies that move the community spaces to the exterior of the building providing more access to daylight and views of nature. These environments should also be highly considerate of the patient perception. Concepts should promote not only safety but dignity, respect and empowerment.

Creating a Controlled Yet Homelike Atmosphere

People enjoy being in environments that make them feel comfortable – clinicians are no exception. When designing for Behavioral Health specifically, it’s important to strike a balance between feeling homelike and creating a safe environment. Some examples include:

• Furniture must be designed specifically for behavioral health but can have a residential feel. Open shelves work great for storing patients clothing while avoiding clothes rods, drawers, and cabinet doors. 
• Incorporating artwork that is durable and cleanable while fastening it securely. Large scale graphics or pictures printed on wall protection can become attractive murals. 
• Providing TVs for entertainment with tamper proof enclosures.
• Integrating adjustable thermostats versus ligature resistant options.  Thermostats in the room can create a ligature point. Instead of thermostats in the rooms, use temperature sensors. Nurses can adjust room temperatures for the patients and patients can still control their environment.
• Lighting controls and tunable lighting can be used to change color temperature and dim lights to mirror the time of day, promoting a good circadian rhythm for the patients. This can also be manually controlled by nurses.

To balance safety and a home-like environment, all key staff must be included in the design process, including physical therapists, occupational therapists, nurses, social workers, etc. Each person’s role provides them with a slightly different perspective so, when combined, designers can address the greatest number of needs and desires.

A Heightened Focus on Security

Another important aspect in designing Behavioral Health facilities is understanding necessary security measures unique to this form of healthcare. In addition to keeping most areas of a Behavioral Health facility locked down, other precautions must be considered for the safety and well-being of patients, staff and visitors. These can include:

• Staff accessible water shut off functions incorporated outside each room in the case of deliberate or accidental flooding issues.
• Nurse call button shut off availability for staff if a patient is abusing this tool.
• Tamper-proof switches and outlet plates.
• The sallyport is a secure vestibule for entering the unit. Incorporating a pass through in the sallyport can reduce unnecessary traffic into the unit for supplies and paperwork, reducing operational challenges. 
• Court camera systems that allow patients to have court visits via video conference. This prevents patients from having to be transferred off the unit and transported via police to different locations.
• When it comes to security, each individual facility is required to test all products and do risk assessments. Just because a manufacturer claims their products are anti-ligature, or resist having something tied or bound tightly to them, it does not necessarily mean this will be the case.  Requesting samples of different products, such as hardware, furniture, fixtures and equipment, before committing will ensure compatibility. Many of these products are expensive and require anywhere between a 10 to 18 week lead time so budget and schedule appropriately.

Applying Behavioral Health Design Resources

There are many excellent references available to guide Behavioral Health design decision making.  Patient Safety Standards, Materials and Systems Guidelines Recommended by The New York State Office of Mental Health is a great help for product selection, risk assessment, and safety strategies, organized by construction specification divisions. The Facility Guidelines Institute also provides insightful principles for the needs of patients and staff in psychiatric nursing units and psychiatric hospitals. 39 states have adopted some edition the FGI Guidelines and require compliance with all or part of the guidelines. The Department of Veterans Affairs Mental Health Facilities Design Guide is another valuable source for recommendations for facility planning and design criteria as well as typical room layouts. 

Lessons Learned

Planning and construction for building projects can be a lengthy exercise, but when taking into consideration the special components of behavioral healthcare settings it is a given. After overseeing construction for several months and dealing with day to day operational challenges for this project, here are some of Jenny’s remaining takeaways.

• Cameras are not a “get out of jail free card.” If cameras are the only monitoring requirement in place, there must be a dedicated person to watch the cameras 24 hours a day with the ability to get to a patient quickly.
• Although helpful to staff, cameras can also cause privacy concerns for patients, with too many cameras making some patients feel anxious or paranoid.
• Continually consider all details in the built environment. Review all conditions while asking yourself if they pose dangers to patients or staff. 
• Have staff test devices like door handles not only for patient safety but also for ergonomics. Some devices that are designed for patient safety can inadvertently cause musculoskeletal injuries for staff over time due to poor ergonomic design. 
• Don’t rely upon minimum code requirements or standards to guide the project. Designers must proactively think about safety risks and the patient experience.

Jenny’s last lesson learned is a simple but profound one -- there is no way to anticipate all the different risks in a behavioral healthcare environment, but you must do your best! Putting yourself in the shoes of caregivers and patients is key to creating a successful behavioral health environment. I learned a few new things during my talk with Jenny and hope that you have too; I’d love to hear from you, what else would you like to hear with a deeper dive on in relation to healthcare design?