By Rick Dahl, AIA, Don Thomas, CID, and Scott Holmes, AIA, ACHA, LEED AP
In 2006, Avera Behavioral Health Center opened in Sioux Falls, S.D., with what some could describe as a significant departure from the traditional approach to providing mental healthcare. The goal was to create an environment that would be safe and secure, respectful and dignified, have a sense of spirituality, and be world-class.
The 130,000-square-foot hospital and medical office building complex was driven by vision and aspirations, a chance to imagine the look of mental health care delivery if given a clean slate and elements of best practices in healthcare.
Leaders and employees from Avera Health together with an experienced healthcare design team from BWBR applied many tried and true healthcare standards but also made many assumptions. The team stretched the boundaries of creating healing environments for mental health, designed new care models, generated many new solutions and, in some cases, took a leap of faith.
The design strategy for the new center represented a departure from the sterile and institutional environments previously available to the region's patients, notably the outdated, fourth-floor unit at Avera McKennan Hospital. It incorporated many design approaches that were not the norm in mental health care in 2006:
In the years since, Avera’s leap is proving to be a giant step forward for patient care and for community perceptions about behavioral health care. Patients find the space to be safe, comfortable, and empowering; staff are proud of the work they are doing and the facility where they practice; most spaces are functioning as designers intended. Leaders have attributed a number of factors to the facility’s success, not least of which is its attractive exterior, its welcoming foyer (Figure 1), and its prominent place in the community.
In 2011, Avera and BWBR conducted focus group studies to evaluate the design strategies utilized in the center and their effectiveness in the care process. The findings affirm many original design approaches, yet also offer some design lessons and opportunities.
The design innovations for Avera Behavioral Health Center included units designed with open community areas instead of long corridors. Rooms, most of them private, border these open areas and include thresholds at the entry of each room that allow patients to enter the space at their own pace (Figure 2). The dayrooms include seating that can be rearranged according to the interactions desired.
To promote the welcoming environment, nurse stations are designed to be open as well, a significant change from the way stations were previously designed in older mental health facilities. It was a change not taken lightly by the staff and leaders who sought to ensure safety remained a priority in the new facility. What staff and patients, alike, have found is that the open design is not only safe, but it is more peaceful and conducive for patients healing and staff working (Figure 4).
Previous design strategies made the nursing station a focal point of the unit where patients, staff and others congregated, increasing the tension level on the unit and risking confidential information being overheard. The unique “wedge” design created for Avera Behavioral Health units uses large windows, skylights, and daylight to encourage patients, as well as their families or visitors, to congregate away from nursing stations (Figures 3 and 4).
Patients said they felt empowered in the facility to have some control. With the open design, staff could allow patients to get their own beverages or snacks, walk through the unit, and sit where they find comfort.
The design of the day area leads patients and family members to use it as a visiting area since it offers the most light and available space. Yet, its placement still allows the nursing staff to have excellent observation of the unit. The only deviation from the serene environment can come from the success of family participation, which, at times, can elevate the noise level beyond that of normal operations.
The intentional lack of an institutional feel to the center removes some of the typical barriers to the relationships between the patients and staff, which patients say makes interactions in and even outside of the center easier to have.
Through deliberate efforts, Avera has created a culture of care and support among its employees, who share a sense of ownership and pride that is felt by families and patients. Patients said they clearly feel the mission of spiritual care in the facility, and many said design elements in the facility, such as the waterfall and two-story light court at the entrance to the center, create a tone of beauty and serenity in the facility.
Another design feature, a double corridor system that separates in-patient areas from public and daily support services helps to protect patient dignity and privacy. Corridors bordering patient rooms can be used for consultation and visits, while the corridor entry into the units eliminates the need to pass through a locked-door, security system. Instead, open, curved nurse stations at the entries provide the main point of security, wrapping around into the units to allow for complete visibility.
One of the most significant practical changes that occurred with the opening of the Avera Behavioral Health Center—a standalone facility several miles from Avera McKennan Hospital—was how patients came to be admitted to the facility. When patients were admitted to the old, fourth-floor behavioral health unit at McKennan Hospital, about 95 percent were admitted directly through emergency department.
With the opening of the standalone center, however, most inpatients presented directly at the center’s entrance—much fewer went to or were referred from the hospital ER. The result was a larger than expected flow of patients and family members in the reception space, which created a need for more private screening areas where staff could triage patients.