Side of Design

A Safe Space to Heal: Balancing Safety and Comfort in Behavioral Health Design

• BWBR • Episode 49

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Like any other healthcare facility, behavioral health environments must be comforting places to heal. But these spaces pose unique considerations to keep patients safe, requiring thoughtful balance from skilled design professionals to create environments that are beautiful and manage patient risk. Senior Interior Designer Lauren Frank, Senior Project Manager Susan Golberg, and Senior Architect Ellen Konerza are a few members of the BWBR team who work to design these facilities, and in the latest episode of Side of Design, they dive in to creating environments that prioritize safety without feeling cold or institutional.

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Matthew Gerstner:

This is Side of Design from BWBR, a podcast discussing all aspects of design with knowledge leaders from every part of the industry. Hello and welcome to Side of Design from BWBR. I'm your host, matt Gerstner. On this episode, we'll be digging into some of the unique challenges in behavioral health design, specifically finding the balance between the risk level of the patient population and a client's unique needs and goals for creating a space that is beautiful, healing and effective. Joining the conversation from BWBR are Lauren Frank, senior Interior Designer, susan Goldberg, senior Project Manager, and Ellen Canerza, senior Architect. Thank you all for joining me today.

Susan Golberg:

Thanks, Matt. Happy to be here. Good to be here. Thanks for having us.

Matthew Gerstner:

I'm just going to dive right in and start with this first question what are some of the unique safety considerations that come into play when designing for behavioral health facilities?

Susan Golberg:

I think from studies we know that the biggest risk in these facilities to patients are from ligature risks, which are hanging risks, and the locations that are the biggest risks are in the private areas, especially the bathrooms and in the patient bedrooms. So we pay particular attention to that, Okay.

Ellen Konerza:

And I might add, just in general, what would make a space safe for somebody who may be in distress would be they know where they're going. It's clear, clear directions, they understand where the different types of spaces are that the patient can go, and acoustics making sure things aren't too loud. Anything we can do to just make a calm environment that's easy to understand, easy to use, can increase the safety of a space that's easy to understand easy to use can increase the safety of a space.

Matthew Gerstner:

That's really fascinating. I love the ideas of trying to just help create a serene environment for the patients, and I'm sure there's things that a lot of people wouldn't think of that can trigger someone, if you will, in those spaces. You're talking about sound. You're talking about being able to find things easily that's that sounds like there's a lot of thought going into all these little different pieces yeah, visual clutter, acoustical clutter, spatial density, social density so you don't want to get too many people in one space at one time.

Susan Golberg:

That causes conflict, so you don't want to bottleneck people. You want to have people to have their enough. Causes conflict, so you don't want to bottleneck people. You want to have people to have their enough personal space and you also don't want to have too many people in one area. Okay, and then other safety things. You want to have secure materials. You may want to go into that a bit, and why.

Lauren Frank:

Yeah, from a finishes standpoint, we want to make sure that they are safe for the different areas. So, like Susan was mentioning, for the patient bedrooms and bathrooms, doing a higher level of finish, things that are seamless, that are going to be ligature resistant, more ligature resistant than some of the more public or observable spaces, right?

Susan Golberg:

and everything's securely fastened so you can't pull it off to have it be a weapon or you can't have a pocket for contraband. Same with furniture. You don't want to have anything for contraband. You don't want to have furniture that you can pick up and use as a weapon, or, if you can, it's really light, you can weight it but it's easily cleanable as well.

Lauren Frank:

Durability and cleanability is super important in these environments.

Matthew Gerstner:

I can imagine. So can we talk about the importance of identifying risk levels you know like early on and how they're used throughout the life of a project.

Susan Golberg:

Then Sure, we start out with a floor plan and we identify each room with a different risk level. We use this to get everybody on the same page. We have the design team talking with the client, with all the stakeholders. We use that through the whole design process. We then go through construction with it, so the contractors are all on the same page, as well as the authorities having jurisdiction who do all the inspections. It goes through that into the users of the space and then also it goes further into the joint commission when they do their surveys. And then, ellen, you had mentioned some yeah, so just a specific scenario.

Ellen Konerza:

Recently we issued kind of an earlier set of documents for a project. So you know there's three to four main design phases throughout a project and you're going to cost estimate that a few times until before it gets to construction, just to make sure it fits with the client's budget. So early on you don't have the specifics of the type of door or windows that you will in a later set of drawing.

Ellen Konerza:

So, you can take this diagram if you will. That shows the different levels of risk for a patient and you can say cost estimate. All of these bedrooms are risk level four, for instance, so they're going to have this type of door or this type of wall finish. It's just an easy way to express the level of durability or safety we need in the products without having to draw all of that which we usually do later in the process.

Matthew Gerstner:

I can see that being super beneficial to just the whole process early on. Yeah, that's that. That's really fascinating.

Ellen Konerza:

I feel like what I've learned is the importance of those. We'll get into the specifics, but those level five high risk, when a patient is just coming into the space and they might be agitated how important it is to think about those spaces. I don't think that before this diagram, at least, I didn't think about them in that way. It really helps to think of what mood the patient is in in these different spaces.

Matthew Gerstner:

Yeah, there's. There's a lot going on with this diagram. That is just amazing, especially early on, and I can see just so many benefits to being able to use this. So can you kind of like talk us through the general risk levels and how they apply in all these different spaces then?

Ellen Konerza:

There's five levels. These come from the behavioral health design guide and there's a lot of different things that informed this the FGI, even the VA design guide. But really what this this is is it's addressing the built environment for adult inpatient mental health and behavioral health unit. It represents the leading current industry practices for these environments and it's it's really just a practical means for us to make sure the spaces are. They protect the patients and the staff from harm. So this is the practical diagram and when you look at it it's got five color.

Ellen Konerza:

Level one is the least risk, so these are spaces where patients aren't allowed. Level five is generally a darker color. This is kind of the high risk or kind of on. You're unsure what type of the patient could be agitated, or just because they're coming into the facility, it could be like a seclusion space if they really are agitated and they need a little bit of time to themselves to calm down before they come back into the general lounge area. So it's a level from one to five and then we generally consider three, the middle of it, to be the baseline. So this is kind of the open lounge spaces, dining areas, usually in the middle of the the patient housing wing or wherever the bedrooms are, where it's generally minimal supervision. You've got staff, kind of either at a desk or mingling with patients here. So that's, you don't need to have the highest, the highest safety requirements in a level three. It still needs to be safe, but you're going to see, it's generally going to be seen if a patient is trying to tamper with something.

Susan Golberg:

So it doesn't need to be as extreme as that seclusion space or, yeah, an intake type of space and then risk level four is typically the where they can be alone, like a bedroom or a quiet room okay so and then we work with so there is some criteria that's been established. That's kind of our base level. That's in this guide, and then we work with the clients to tailor what the criteria is for each of these diverse levels.

Ellen Konerza:

Yeah, so that's what I was going to say is these these are set up only for adult inpatient units.

Matthew Gerstner:

Oh, okay units.

Ellen Konerza:

It's up to us as the design team and engaging the staff and the nursing staff and the people actually working in these spaces. They need to help us understand the patient population child and adolescent medical care needs, geriatric substance abuse, eating disorders All of these things are on top of this kind of baseline set of criteria that we need to hear from the facility and the staff.

Susan Golberg:

And there's some that you know you can relax some of it, and you know it can. It can go both ways more strict or less strict. We need to be able to flag things that we think are problematic, or you know other things that we think that they'll be fine, but they need to be able to flag things that we think are problematic or other things that we think that they'll be fine but they need to mitigate it. They'll figure out procedurally how they would mitigate something and they would put that in their operational narrative.

Matthew Gerstner:

Okay, this, I mean this just sounds like an incredible tool to have early on, because I did some behavioral health work in my past as well. So not having that and now hearing about what's available, this is pretty cool. So I would have to imagine also that with having these different layers or different levels of risk assessment, that the finishes and the furniture and that kind of thing is also broken down then to fit into those levels. So then early on when you're looking at pricing, as we were mentioning before, you've got some specific items that are kind of in those categories, that are in certain price ranges.

Lauren Frank:

Correct, yeah. So for level five, the highest risk level for the walls and floor, we would want a fully adhered product with welded seams, no baseboards, super cleanable surfaces and a hard lid ceiling with ligature resistant hardware and fixtures yeah, and then all the way down to a level one which would be standard fixtures and finishes.

Matthew Gerstner:

Okay, so something more in like the lines of like an office type.

Lauren Frank:

Correct. Yeah, typically our level one, our staff, only spaces, so patients wouldn't be allowed. But the mid level three, like Ellen and Susan were talking about, it would really depend on how high can the ceilings be. Would determine the type of ceiling and fixtures that might be used. Yeah, of ceiling and fixtures that might be used.

Matthew Gerstner:

Yeah.

Lauren Frank:

And floor and walls. A little bit comes down to the client and what their preference would be, keeping in mind the safety and durability and overall calming aesthetic of the space.

Matthew Gerstner:

That's awesome. So then, how might these levels be modified by age group or client, and do you like have any examples of that kind of thing? So what Lauren was talking about with the ceiling heights, for instance, age group or client, and do you like have any examples of that kind of thing?

Ellen Konerza:

so what lauren was talking about with the ceiling heights. For instance, you can imagine someone younger running down a long hallway and the ceiling height might if it's just nine feet or something they're just running down easy to jump up and pop that ceiling tile up. So it's definitely important to think about the age group on those ceiling heights. Geriatric patient, for instance, probably wouldn't be popping those ceiling tiles up as easily probably not yeah, on pine rest we did a lot more adult protection.

Susan Golberg:

We had a lot more consideration on just we didn't have any open chipboard. We had a bigger sensory room with more activity kind of space in it and you can maybe tuck it to kind of that stuff too, maybe talk more the sensory stuff with the autism yeah, yeah, so sensory or de-stimulation rooms, as they're sometimes called, are really spaces where a patient can go in and have some control over the music, the lighting, any sounds, the color.

Lauren Frank:

Sometimes we do color, changing cove, really anything to help the patient feel more comfortable and calm so that they're, when they're ready, they can come out of those rooms and join the general milieu in the lounge type spaces I love the idea of those sensory rooms.

Ellen Konerza:

Yeah, just to help de-stimulate, just calming have you ever changed the uh finishes or the things that you provide in a sensory room based on patient population?

Lauren Frank:

Yes, yeah.

Lauren Frank:

So usually if it's a child and adolescent sensory or de-stimulation room, we've done bubble tubes.

Lauren Frank:

We've catered more towards what someone who's younger might be more interested in. So I would say one example that comes to mind was a child and adolescent unit and they had a de-stimulation room that had a giant projector wall that had different games and color changing light activities. It integrated with music and sound systems and there was a higher level of acoustics in that room just because it had more of that active activity type of vibe. So for kids it's usually geared more towards what a kid would be interested in. And someone with autism, we might look at fiber optics or changing the lights, changing the sounds, but similar things would be done for an adult changing the sounds, but similar things would be done for an adult. Usually the adult rooms have recliners or some sort of more calming, less active type of activity where you might just be listening to sounds of nature, raindrops or birds and adjusting, dimming the lights down, versus having a more color changing, active type of space versus having a more color changing active type of space.

Matthew Gerstner:

Ok, ok, so it sounds like these specific projects have a lot of risk associated to them. There's a lot of opportunity or chances associated for things to go into a negative direction potentially, and it sounds like you're trying to do a lot of things to help mitigate that throughout the entire life of the project. So you mentioned something specifically like ceilings. I mean, alan, you mentioned how, if it's a younger group and they're running down the hallway and they jump up, they could easily pop ceilings open. How do all these things come into play? What kind of things are you doing? I mean, it sounds like there's a lot of risk. What happens if a ceiling tile pops open?

Susan Golberg:

What are we trying to prevent them from doing? So what happens is it presents a ligature risk from the ceiling grid. So we really have to watch that. So typically, if a ceiling is 10 feet or above, we consider that okay to use a lay-in ceiling. We really want the benefit of a larger space or a group space, the acoustics from a lay-in ceiling and if it's below that height you really want a hard lid. However, if you have in talking with the stakeholders, the staff really know the patients and their programs and if we have a circumstance where we can't get a 10-foot ceiling and let's say it's 9'6", the staff may say you know, we're fine with a land ceiling here. We think it's more important that we have the acoustics for the therapeutic elements of the space and this is supervised and we'll take on that risk. So we'll modify in this room the criteria for that risk level.

Matthew Gerstner:

Okay, it sounds like you're engaging staff in a lot of these conversations early on, and so this is just one aspect of how staff comes into play when you're doing these discussions. Do they come into play throughout it even more?

Ellen Konerza:

I was going to add, in addition to the ligature risk, a lot of times these products could be, if it's broken off, it could be used to hurt themselves or to hurt somebody else, or even ingested. Or sometimes, you know, we have to have a water fountain in certain spaces, but some patients drink a lot of water, so it needs to be regulated. So the only way to hear about those risks are from the staff who work with the patients in that unit. They're really important in every decision that I honestly feel, like a lot of other projects I've been on, it's just you just put the water fountain there and you don't question it, and it's really important to talk about each specific piece of equipment here in these types of projects.

Matthew Gerstner:

I can absolutely see that you wouldn't think about it as a good centralized location. This is a great spot for a water fountain, but that's not going to fly in this particular location. So, with all this in mind, how do you help clients weigh these risks with the rewards and explore options for design and mitigation?

Ellen Konerza:

I really think that we, as architects of these spaces and designers, we get to see different projects and how they've solved certain concern and we can share these solutions to other clients because we've seen it in other projects. They could also, I guess, tour other facilities. But right, it's a real great, baked in way throughout the design of the project, to say, you know, in the beginning of design this building took on this shape or had this many bedrooms. To the end of the design, well, this project over here had this kind of water fountain. Let's, let's maybe try one here. It might solve this concern.

Lauren Frank:

Well, and I think to the New York guide that gets updated every six months to a year. They're constantly reviewing new products and evaluating their risks. They have their own internal risk assessment to what they're gauging a product on, so then we can bring that back and share that information as well, similar to what Ellen was saying, where, seeing what other clients are doing and sharing that information client to client, we can also look at what the industry is coming up with. Different vendors are constantly inventing and coming up with new ligature resistant products that we can then bring to our clients to have them test and give us their feedback on.

Matthew Gerstner:

That's fancy. Is that a publication you said that comes out every like six months?

Lauren Frank:

It gets updated every six months, ellen, you might know more.

Ellen Konerza:

Yeah, it gets updated quite often. I don't know if it's every six months, but we've actually had projects where something that was recommended in a past project they've learned since then, may not be as safe as they thought. If I remember right, shower curtains come to mind, right. That's something where they learned a little down the road that if what you're hanging it from can only support a certain amount of weight, but if you gang together all of the clips, it can support, you know, five times that weight.

Susan Golberg:

so, wow, so the designs evolve, yeah, yeah and they'll change the different risk levels within there too, because it's a high, medium, low that they'll assign to each product.

Matthew Gerstner:

Well, that just sounds like an invaluable tool throughout the entire process.

Ellen Konerza:

The New York State Office of Mental Health. In addition to just products, they have different blurbs in the beginning of each section. So in the beginning of each one they kind of recommend as well if you can create a shower that doesn't need curtains, this is the safest way to go. So that's a great design tip to have. When you're in the beginning of design, you're not thinking about curtains. But, man, if you can have a bathroom that's big enough to also hold a shower, you're going to be so far ahead of the game, because struggling during construction phase to find the right shower curtain is really hard.

Matthew Gerstner:

Oh, I can imagine. Do we want to touch on how the joint commission surveys and product endorsement guidelines change over time and how that impacts renovations as well?

Susan Golberg:

Yeah, just as we were talking about that New York State guideline. So the products change and the guides come out. I think it's time to six months, I think it's just periodically. Every time they have products change and you can select something from that guide and it'll be state-of-the-art for when the facility opens. But a few years later the Joint Commission can come through and flag it. So let's back up a minute. So the Joint Commission does surveys for CMS. So if your facility wants to have reimbursement for Medicare or Medicaid, then you need to be surveyed by the Joint Commission and you can sometimes find a CMS consultant to try to get an opinion on things. But I think you just want to err on the side of caution. And it does, I guess, change over time, because it used to be that they were more considerate of if it was a supervised space. They put more weight on that and I think I'm finding more and more that even if it's a supervised space, they still want to have ligature reduced risk.

Matthew Gerstner:

I can imagine at the end of the construction phase, making changes is the worst time to make changes it's after construction, I mean it's it's you know years later that they come in and do their surveys?

Susan Golberg:

oh goodness, so it's not even you know, it's after you.

Matthew Gerstner:

You're get your occupancy and you're in the place and that's when they're coming in and doing all the surveys.

Ellen Konerza:

Well, after it's occupied and running yeah, and it's not just you know, one room one, it's usually all 50 bedrooms or whatever.

Susan Golberg:

Yeah, you know it's multiplied yeah, the hardware in the store is no longer acceptable. You need to change them all and you have this many weeks to be able to do it, for this many days to be able to do it.

Matthew Gerstner:

So, even if that was acceptable, when the project was completed construction and opened, they can come back and say that yes, that's not cheap.

Lauren Frank:

No, it's not, but it is for the benefit and safety of the patients. That's the flip side of this coin. We want to make sure that these spaces are safe for these patients absolutely get it.

Matthew Gerstner:

Are they only looking at the physical structure of the building things that are built, or are they looking deeper into how things operate there too?

Ellen Konerza:

as I understand it, they're also looking at how things operate.

Matthew Gerstner:

Okay, so that comes into play in their recommendations and when they come through and check things out.

Ellen Konerza:

The nurses even use this and the joint commission uses this diagram they do To help feed into their. Okay, you've got a level five space here. What is in your risk mitigation plan? If there's someone in this room that does X, y or Z, yeah what?

Lauren Frank:

is in your risk mitigation plan. If there's someone in this room that does X, Y or Z, it's a good diagrammatical tool to be able to say these are the different spaces, these are the risk levels based on how the clients have described their patients using them unit, so that if the joint commission comes they have a diagram and document to back up why decisions were made and why which room types are the way they are.

Matthew Gerstner:

That's fantastic. That sounds like something that can be used. So you started out early in schematic design and you're identifying all these different levels and these spaces and it's being used all the way through construction. But then, even after construction, it's still being incorporated into the processes and how things are being run.

Lauren Frank:

Exactly.

Matthew Gerstner:

That's amazing and is it something would you say it's like a living document then that if they make renovations and changes, then these diagrams or the risk assessment levels, are changing based on what's happening in the future, though?

Susan Golberg:

Yes, absolutely.

Matthew Gerstner:

Amazing. So how do these negotiations and conversations fit within BWBR's overall philosophy and approach to behavioral health care design then?

Susan Golberg:

So human-centered safety is. Bwvr's holistic, integrated approach to behavioral safety is priority, but not at the expense of patient dignity and choice. We need to be creating a therapeutic healing environment. We don't want it to feel punitive or institutional. We don't want to have the space defeat the patient before they walk in.

Ellen Konerza:

Yeah, the not institutional and specifically home-like, because there's a lot of safe products out there that just look weird Like they're from the 70s or it's just way oversized for what it should be.

Lauren Frank:

So making sure you're using those things appropriately yeah, making it not look scary or, like Susan was saying, institutional in any way, making it home-like and calming and bringing nature in so that it feels really welcoming, inviting, calming, like a place where you could get better.

Susan Golberg:

And it's a balancing act. We'll never be able to get any place risk-free. We just want to try to reduce the risk. The goal is to create a comfortable healing environment by accommodating all of the patient's need, but really prioritizing safety for both the patients and the staff.

Ellen Konerza:

And that you would want your you know a family member.

Matthew Gerstner:

You would feel comfortable dropping off a family member at one of these facilities. Thank you all so much for your time and insights today it's been a pleasure to talk to all three of you.

Ellen Konerza:

Thank you, matt, thanks, thank you.

Matthew Gerstner:

This has been Side of Design from BWBR, brought to you without any paid advertisements or commercials. If you found value in what you've heard today, give us a like, leave us a comment or, better yet, share us with your network. You can also reach out to us if you'd like to share an idea for a show or start a discussion. Email us at sideofdesign at bwbrcom.