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Risk tolerance - fiscal and physical responsibility

August 12, 2012
by James M. Hunt, AIA
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Every facility that admits and treats behavioral health care patients either consciously or sub- consciously determines its level of risk tolerance for a multitude of issues pertaining to its built environment.

 The sub-conscious decisions may range from simply not knowing that a condition creates a potential saety risks for patients and/or staff to organizations hiding their collective head in the sand and choosing to ignore the threat. 

 There are many reasons or rationales for ignoring these issues.  Two of the leading causes, in my opinion, are the following:

1. The most time honored excuse for not implementing suicide prevention measures and improvinf patient and staff safety is the almighty dollar.  Changing things will probably cost money and that is very hard to come by these days for all facilities.

2. The current trend towards making behavioral health facilities more “home-like” and “less institutional” encourage us to look the other way regarding safety risks in order to jump on the current bandwagon.

 COST: It never ceases to amaze me that there is never enough money to pay for patient and staff safety upgrades before there is a serious incident, but there is plenty of money to pay for improvements after there has been a sentinel event.  The cost of correcting environmental hazards is often much less than paying for the lawyers’ fees and settlements or long-term higher insurance premiums after the fact.  Those expenditures do nothing to relieve the hazardous conditions on the unit.  This seems to me to be misguided fiscal responsibility

 RESIDENTIAL CHARACTER: Readers of my other blogs on this site will realize that I am not a big fan of the current popular phrase “evidence based design”.  The accompanying figure is not based on any scientific research or study of any kind.  It is provided simply to illustrate a conclusion that is solely based on my thirty years of experience.  Arguably, the safest location for a patient on a unit is the seclusion room.  They have a very high level of supervision and the most “institutional” space in any facility.  Granted, incidents do occur in seclusion rooms, but this is where patients have the least amount of freedom.  The opposite corner is possibly represented by a day room where patients are not under constant supervision and such items as accessible ceilings, unlocked cabinet doors or possibly even table lamps are present.  Another example of this higher risk area could be a patient toilet room with typical residential toilet fixtures and accessories.  Generally, the risk level increases with the amount of time a patient is alone and unsupervised in a specific location.  Also, the risk level generally decreases with more “institutional” type finishes, door hardware and other accessories. 

 CONCLUSION: Every item that is visible and accessible to patients in the entire unit should be evaluated and a determination made as to the amount of risk that is acceptable for that item in that location for the patient population and staffing level provided. 


Jim Hunt

Behavioral Healthcare Design Consultant

Jim Hunt


James M. Hunt, AIA, is a practicing architect and facility management professional with over 40...

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