Design mistakes, Part 1: things many 'know' that 'just ain't so': consultant warns that a little bit of 'knowledge' can be a dangerous thing.
Subject: Psychiatric hospital care
Psychiatric hospitals
Author: Hunt, James M.
Pub Date: 11/01/2012
Publication: Name: Behavioral Healthcare Publisher: Vendome Group LLC Audience: Academic; Trade Format: Magazine/Journal Subject: Health; Health care industry; Psychology and mental health Copyright: COPYRIGHT 2012 Vendome Group LLC ISSN: 1931-7093
Issue: Date: Nov-Dec, 2012 Source Volume: 32 Source Issue: 6
Product: Product Code: 8063000 Psychiatric Hospitals NAICS Code: 62221 Psychiatric and Substance Abuse Hospitals SIC Code: 8063 Psychiatric hospitals
Accession Number: 313161187
Full Text: Preliminary meetings involving architects, psychiatric hospital management, and unit staff members often result in decisions that crystallize into critical details of facility design very early in the planning process. These can be very difficult, if not impossible, to change later on.

During these sessions, it is not unusual for psychiatric hospital staff to state any. number of time-honored platitudes that, through sheer repetition, have come to be "known" as unchallengeable facts of psychiatric facility design. Typically, staff comes to "know" such things because they have heard them throughout their professional lives in the facilities in which they have worked.

But using such "common knowledge" to work in designing new psychiatric facilities can be very problematic and very costly. Former baseball great Satchel Paige explained the problem best when he said, "It's not what you don't know that will hurt you; its what you 'know' that just ain't so."

And so it is, I find, with the design of psychiatric hospitals. The intelligent and highly educated people who are brought together in preliminary design meetings frequently fail to consider whether there is evidence to support what they have come to "know" about psychiatric facility design. If there is not, then their idea has no claim to being "evidence based design" and we must say it just ain't so."

The flawed assumption of similarity

At the root of many of the design ideas that "just ain't so" is a bad assumption, an assumption that is shared by some practicing architects and many hospital administrators. The assumption is that, from a design standpoint, psychiatric hospitals are essentially similar to general hospitals and, therefore, the traditional or "evidence based" design ideas that evolved in general hospitals remain valid in psychiatric hospitals as well.


I know that this assumption is wrong. I know because my consulting practice continues to be called upon by the owners of new or renovated psychiatric hospitals to develop remedial solutions for problems that were literally designed into their facilities.

To see why the design features of psychiatric hospitals must be significantly different from those of general hospitals, one need look no farther than the design and function of the patient room in a general hospital and consider how its design and functional requirements differ from those of a psychiatric hospital (See figure 1).

Erroneous assumptions in psychiatric hospital design

Based on the many design-related discussions I've heard over the years, and after having addressed many of the problems that erroneous design ideas have caused, I've developed a short list of the most common and problematic design ideas that I've heard. Here they are, together with a few suggestions that might help designers respectfully, yet effectively, refocus problematic ideas into safer, more cost-efficient and more appropriate solutions.

(1.) Virtually all behavioral health/psychiatric hospital facilities can be built around a single, state-of-the-art planning model.

Models such as "treatment mall" or "house/neighborhood/downtown" may work well for facilities with long lengths of stay--such as state hospitals--but not so well for hospitals with 5-7 day average lengths of stay or varied patient populations. Generally, the treatment mall concept assumes that all patients will move from the unit to the treatment mall during the daytime on weekdays. Yet, some facilities built around this model have found that often there are patients who are too upset/too unstable to leave the unit. Because these patients must stay behind on the unit, staff must also stay behind, a problem that complicates staff assignments and drives up staffing costs.

Staff in units with 3-7 day average lengths of stay often report that their patients are not stable enough to move off the unit. Accordingly, they recommend that patients be kept within the unit for their relatively short period of treatment.

I've come to believe that terms like "treatment mall" or "house/neighborhood/downtown" are often used rather loosely--as a fashionable way to refer to different portions of self-contained units that provide required facility functions rather than as terms that reference the kind of long-term treatment environment referenced above. I recall one recent discussion with an architectural firm that stated that they are firm believers in the house/neighborhood/downtown model for behavioral health/psychiatric facility development and that they "would not hire any consultants that were not in agreement with that approach."

This sounds dangerously like proposing a one-size fits all solution before the variables are known. The fact is that the design of behavioral health/psychiatric facilities must account for many factors: patient populations, average lengths of stay, diagnoses, acuity levels, staffing patterns, and organizational cultures, among others, to be highly effective.

(2.) "Suicide assessment tools now available are reliable."

This addresses an issue that is located in the very core of many clinical decisions that are made on a behavioral health unit and may not be well received. Asking the following questions may provide a way to get clinical staff to open up and entertain the idea that this may need to be revisited.

Question 1. How do you know which patients are suicidal? The response will likely be that they utilize one of the various risk assessment tools or suicidality scales that are available for this purpose.

The following information may be useful in getting the hospital staff to consider the fact that this mindset could be dangerous and may create a situation which could result in patient deaths by suicide.

Response 1:

The American Psychiatric Association has released several studies on inpatient suicides in inpatient psychiatric units:

* The 2003 study (1) showed that 1,500 inpatient suicides occurred annually and that 1/3 of those patients were on 15-minute checks. (Placing patients on 15-minute checks is often standard practice for patients that have been identified as being actively suicidal. This practice will be discussed in more detail in Part 2 of this article.) Perhaps the more significant conclusion that can be reached from these studies is that 2/3 (or over 1,000 deaths) were patients that staff had not identified as being suicidal and placed on 15-minute checks.

Response 2:

In March of 2012, the Veterans Hospital Association released a study that concluded that the assessment tools that they are using are not reliable. This study is titled "Suicide Risk Factors and Risk Assessment Tools: A Systematic Review." (2) It was conducted by the VA's Evidence-based Synthesis Program. The entire report is available for download at:

In response to the question, "What assessment tools are effective for assessing risk of engaging in suicidal self-directed violence in Veteran and military populations?" the conclusion stated on page 35 of this document is "Insufficient evidence overall to recommend screening with these risk assessment tools based on this evidence. Future research is warranted, particularly for risk assessment instruments that are already in use within the VA System."

This report also asks the following question on page 95: "Are there any clinical performance measures, programs, quality improvement measures, patient care services or conferences that will be directly affected by this report? If so please provide detail." Conclusion #5 under this question is that there is a "... lack of data to support the use of specific risk assessment instruments ...".

In short, the suicide risk assessment tools currently in use by the VA hospital system were found to be unreliable. There is some impressive work being done by several groups to develop more reliable assessments, but most of them are not ready for widespread use at the present time.

Therefore, since many decisions regarding the design of patient use facilities hinge on knowing the suicide risk for individual patients at a given time, and because this information is largely obtained from risk assessment tools that have been judged to be unreliable, it is more prudent to design all patient accessible areas to be as suicide resistant as possible.

RELATED ARTICLE: Different facilities, patients, functions

General hospital patient rooms are typically the site of the majority of patient treatment, dining and visitation. The patient, who is usually non-ambulatory, seldom leaves the room except to obtain specialized treatment or a bit of exercise. Because in-bed treatment is the norm, general hospital rooms typically feature overhead lighting, medical gas outlets and associated tubing, cubicle curtains and theirtracks, in-room sharps disposal containers, and electronics and their related controls.

General hospital bathrooms are also designed to meet the typical needs and expectations of patients with limited strength and mobility. These needs include such as privacy, safety, and convenience, so they feature ample overhead lighting, conventional sinks and mirrors, plus easy-to-use faucet and shower control handles and grab bars, plus easy-to-reach electrical outlets and storage shelves.

Behavioral health or psychiatric hospital facilities assume that patients are ambulatory and that patient rooms are generally used only during designated sleeping or resting periods. Patients typically spend virtually all their other waking hours (therapy, dining, social time, exercise, visitation) in common areas or special-purpose rooms, both of which are readily accessible and observable by staff.

Because of the importance of preventing suicide, or harm to self or others, it is imperative that designers find "safer" alternatives for many of the fixtures and furnishings that are common to general hospitals. These include:

* potential ligature devices (cords, tubing, textiles);

* potential ligature attachment points (shower or faucet hardware, grab bars, doors/door hardware, curtains, curtain racks or draperies);

* sharp or breakable objects (glass lights, mirrors, sharps containers, electronics); and,

* potentially dangerous or flammable gases.

And, because patients may be admitted to behavioral health or psychiatric hospital facilities against their will, physical and facility security is also important to prevent patient access to unauthorized areas or patient elopement/escape.


(1.) American Psychiatric Association, (2003). Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. American Journal of Psychiatry, 160, 1-60.

(2.) Haney EM, 0. M. (2012). Suicide Risk Factors and Risk Assessment Tools: A Systematic Review. Washington, DC: Department of Veterans Affairs.


James M. Hunt, AIA, is the president of Behavioral Health Facility Consulting, LLC in Topeka, Kansas. Hunt is the co-author of the "Design Guide for the Built Environment of Behavioral Health Facilities" that is published by the National Association of Psychiatric Health Systems and available at
General Hospital       Psychiatric Hospital

Patient        - Physically ill/      - Mentally in crisis or
condition:     injured;               substances;

               - Non-ambulatory;      - Ambulatory

               - Admission:           - Admission: Often
               Vo1untary              non-voluntary

Function of    - Rest                 - Rest
patient rooms

               - Treatment

               - Nutrition

               - Visitation

               - Unstructured time

Principal      1) Medical treatment.  1) Patient safety: Resist
design         Lighting, access,      suicide, self-injury, or
concerns for   power for use of       staff injury by
patient        monitors, IVs,         eliminating:
rooms:         wiring, electronics,
               cords, gases,

               2) Patient privacy.    - Potential ligature
               Curtains, curtain      devices or ligature
               tracks, room and       attachment points.
               restroom doors,
               clothing closet.

               3) Patient comfort,    - Breakable lighting,
               safety, and convenien  equipment, or furnishings
               Easy-access controls   that be used to harm self
               (bed, TV, intercom);   or others.
               easy-adjust handles
               (faucet, shower,
               toilet); easy-access
               mirror, outlets,

                                      - Enclosed areas suitable
                                      for contraband storage.

                                      2) Patient observation,
                                      based on changing
                                      behavioral health risk or
                                      safety status.

Function of    Access/transport to    - Therapy
common areas:  specialty treatment    (group/individual)

                                      - Nutrition

                                      - Vsitaton/Sociazation

                                      - Exercise/Unstructured
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