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The range of psychiatric facilities includes psychiatric hospitals, psychiatric and neuro-psychiatric nursing units of general hospitals, facilities for the psychiatric medically infirm, geropsychiatric units, alcohol and drug addiction treatment facilities (both inpatient and outpatient), mental health clinics, day hospitals, day treatment centers, and others.
In addition to inpatient nursing units, psychiatric hospitals include their associated diagnostic and treatment areas, as well as the necessary dietetic, supply, housekeeping, and administrative spaces common to all hospitals. They do not generally include the complex and high-tech diagnostic and treatment areas of general hospitals.
Psychiatric hospitals may include outpatient psychiatric areas. These areas should be located on a direct path from the lobby, and circulation paths of the outpatients should be separated from the paths of the more acutely ill inpatients. Teaching hospitals will also include spaces for training and education, and often spaces for research studies.
The mental health clinic is the basic outpatient unit, providing an interface between inpatient care and the community. As such, it provides preventative care, primary care, and aftercare. The clinic may also serve as a site for research and for training of mental health professionals on all aspects of outpatient treatment of mental health problems.
A substance abuse clinic provides outpatient care and treatment of alcohol and/or drug-dependent patients no longer needing inpatient care. In a hospital, it should be so located that its patients do not need to travel through other parts of the hospital.
The day hospital has no beds, but is typically located within or adjacent to a hospital. It offers total hospital psychiatric services for acutely ill patients without removing them from the family and community.
The day treatment center provides a supportive learning environment away from a hospital in which patients having chronic difficulties with community adjustment and other psycho-social problems may receive help. Such patients have often had long periods of hospitalization, and need continuing monitoring of their general health and medication needs.
Efficiency and Cost-Effectiveness
The design of a successful psychiatric facility should:
- Promote staff efficiency by minimizing distance of necessary travel between frequently used spaces
- Allow easy visual supervision of patients by limited staff. Nurse stations on inpatient units should be designed to provide maximum visibility of patient areas.
- Include all needed spaces, but no redundant ones. This requires careful pre-design programming.
- For inpatient units, provide a central meeting area or living room for staff and patients and provide smaller rooms where patients can visit with their families
- Make efficient use of space by locating support spaces so that they may be shared by adjacent functional areas, and by making prudent use of multi-purpose spaces
The character of the immediate surroundings can have a profound affect on the psyche of a psychiatric patient. The New York Psychiatric Institute reports a dramatic drop in the number of patients who need to be restrained since occupying their new facility with its bright open spaces. Every effort should be made to create a therapeutic environment by:
- Using familiar and non-institutional materials with cheerful and varied colors and textures, keeping in mind that some colors and patterns are inappropriate and can disorient older impaired patients, or agitate patients and staff. See also VA Interior Design Manual.
- Admitting ample natural light wherever possible.
- Providing a window for every patient bed, and views of the outdoors from other spaces wherever possible. Views of nature can be restorative.
- Providing inpatients with direct and easy access to controlled outdoor areas
- Providing adequate separation and sound insulation to prevent confidential but loud conversation from traveling beyond consulting offices and group therapy rooms.
- Giving each patient as much acoustic privacy as possible—from noises of other patients, toilet noises, mechanical noises, etc.
- Giving each patient as much visual privacy, and control over it, as is consistent with the need for supervision.
- Giving each inpatient the ability to control his immediate environment as much as possible, i.e. lighting, radio, TV, etc.
- Providing computer stations for patient use when patient profile and treatment program allow.
- Designing features to assist patient orientation, such as direct and obvious travel paths, key locations for clocks and calendars, avoidance of glare, and avoidance of unusual configurations and excessive corridor lengths.
- Designing a "way-finding" process into every project. A patient's sense of competence is encouraged by making spaces easy to find, identify, and use without asking for help. Color, texture, and pattern, as well as artwork and signage, can all give cues. (For a guide to clear signage, see VA Signage Design Guide.).
- Providing exercise equipment for patient use where appropriate for the program of care.
- Providing access to kitchen facilities, preferably on the unit, where snacks or meals can be prepared by patients, when patient profile allows.
Psychiatric facilities should be easy to clean and maintain. This is facilitated by:
- Appropriate, durable finishes for each functional space
- Proper detailing of such features as doorframes, casework, and finish transitions to avoid dirt-catching and hard-to-clean crevices and joints
- Adequate and appropriately located housekeeping spaces
- Incorporating O&M practices that stress indoor environmental quality (IEQ)
Aesthetics is closely related to creating a therapeutic environment. It is also a major factor in a facility's public image and is thus an important marketing tool for patients and staff. Aesthetic considerations include:
- Use of new lighting systems, high performance glazing, increased use of natural light, natural materials, and colors
- Use of (soothing, not exciting) artwork
- Attention to details, proportions, color, and scale
- Bright and open public and congregate spaces
- Comfortable and intimately scaled nursing units and offices
- Compatibility of exterior design with surroundings
Security and Safety
The potential suicide of patients is a special concern of psychiatric facilities. The facility must not unwittingly create opportunities for suicide. Design to address this and other safety and security issues includes:
- Plumbing, electrical, and mechanical devices designed to be tamper-proof
- Use of breakaway shower-rods and bars, no clothes hooks
- Elimination of all jumping opportunities
- Control of entrances and exits by staff
- Provision for patient bedroom doors to be opened by staff in case of emergency
- Laminated glass for windows in inpatient units
- Fiber-reinforced gypsum board for walls
- Special features in seclusion rooms to eliminate all opportunities for self-injury, including outward opening door with no inside hardware
- Careful consideration of appropriate locations for grab bars and handrails. Where they must be used in unsupervised spaces, and patient profile justifies extra care, special designs are available that preclude their use for self-injury.
- Eliminate the use of door knobs and handles
- Solid material specified ceilings
Psychiatric facilities are public buildings that may have a significant impact on the environment and economy of the surrounding community. As facilities built for "caring", it is appropriate that this caring approach extend to the larger world as well, and that they be built and operated "sustainably".
Section 1.2 of VA's HVAC Design Manual is a good example of health care facility energy conservation standards that meet Energy Policy Act of 2005 (EPACT) and Executive Order 13693 requirements. The Energy Independence and Security Act of 2007 (EISA) provides additional requirements for energy conservation. Also see USGBC's Leadership in Energy and Environmental Design (LEED) for Healthcare.
The HIPAA (Health Insurance Portability and Accessibility Act of 1996) regulations address security and privacy of "protected health information" (PHI). These regulations put emphasis on acoustic and visual privacy, and may affect location and layout of workstations that handle medical records and other patient information, paper and electronic, as well as patient accommodations."
There is a continuing shift to outpatient psychiatric care as new and more effective drugs are developed for the classic psychiatric conditions. Many of the homeless in our urban areas are ex-psychiatric inpatients who receive little or no follow-up outpatient care. There is a large unmet need for supportive housing and/or treatment facilities for them.
There is also a great need for effective treatment of drug addiction and alcoholism, particularly among the poor. This issue is also related to homelessness.
Relevant Codes and Standards
Health care facilities are among the most regulated of all building types. Like other buildings, they must follow the local and/or state general building codes. However, federal buildings on federal property generally need not comply with state and local codes, but follow federal regulations. To be licensed by the state, design must comply with the individual state licensing regulations. Many states adopt the FGI Guidelines for Design and Construction of Health Care Facilities as a resource, and thus that volume often has regulatory status.
State and local building codes are based on the model ICC IBC International Building Code. Federal agencies are usually in compliance with the IBC except NFPA 101 (Life Safety Code), NFPA 70 (National Electric Code), and Architectural Barriers Act Accessibility Guidelines (ABAAG) or GSA's ABA Accessibility Standards takes precedence.
Facilities which treat patients who are reimbursed under Medicare must also meet federal standards, and to be accredited, they must meet standards of The Joint Commission. Generally, the federal government and The Joint Commission refer to the National Fire Protection Association (NFPA) model fire codes, including Standards for Health Care Facilities (NFPA 99) and the Life Safety Code (NFPA 101).
The Americans with Disabilities Act (ADA) applies to all public facilities and greatly affects the building design with its general and specific accessibility requirements. The Architectural Barriers Act Accessibility Guidelines or GSA's ABA Accessibility Standards apply to federal and federally funded facilities. The technical requirements do not differ greatly from the ADA requirements. See WBDG Accessible.
Federal agencies that build and operate psychiatric facilities have developed detailed standards for the programming, design, and construction of their facilities. Many of these standards are applicable to the design of non-governmental facilities as well. Among them are:
- Department of Veterans Affairs (VA), Office of Construction & Facilities Management Technical Information Library contains many guides and standards, including Design Manuals of technical requirements, equipment lists, master specifications, room finishes, space planning criteria, and standard details.
Federal Mandates and Criteria
- Executive Order 13693, "Planning for Federal Sustainability in the Next Decade"
- UFC 4-510-01 Design: Military Medical Facilities
- Design Considerations for Mental Health Facilities by AIA Committee on Architecture for Health. Washington, DC: AIA Press, 1993.
- Design Details for Health: Making the Most of Design's Healing Potential, 2nd Edition by Cynthia A. Leibrock and Debra Harris. New York: John Wiley & Sons, Inc., 2011. — Innovative design solutions in key areas such as lighting, acoustics, color, and finishes
- Psychiatric Services — Journal of the American Psychiatric Association primarily focused on treatment of mental illnesses, but carrying occasional articles dealing with facilities.
- Sound & Vibration: Design Guidelines for Health Care Facilities by the Acoustics Research Council. 2010.