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Design mistakes, part 1: Things many ‘know’ that ‘just ain’t so’

December 3, 2012
by James M. Hunt, AIA, NCARB
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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; it’s 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.

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.




I've read Mr. Hunt's "Design Guide", and certainly appreciate his thoughtful analysis of psychiatric systems. But I take issue with several points, including the discounting of validity of suicide assessments, and his use of "1500 inpatient suicides yearly". I have no idea where that figure comes from, unless he is including forensic settings or other non-psychiatric community facilities.

Michael Fitzgerald.