Once upon a time, when inpatient psychiatric facilities were still called
asylums, the building was the treatment.
"Moral treatment placed the disordered mind in an orderly,
predictable place, usually in a calming pastoral setting, to provide a respite
from the social chaos of the city in an age of rapid growth," said
Virginia Susman, M.D., at APA's 2008 annual meeting last month in Washington,
D.C. She is an associate medical director of New York-Presbyterian Hospital in
White Plains, N.Y., and an associate professor of clinical psychiatry at Weill
Cornell Medical College.
The long passage of the classic 19th-century asylum from first line to last
resort is well known, according to Susman. Today, the need for inpatient
psychiatric units and hospitals remains, but constructing a therapeutic space
means finding creative solutions to conflicting demands posed by myriad
federal, state, and professional regulations.
"Anyone involved with design has to struggle with the tension and
balance among safety, treatment, and dignity," said Susman. For
instance, staff need to observe patients in the hallway or common rooms, but
patients may want their privacy.
Susman's interest in the question was stimulated after an adverse incident
occurred in 2005 in a nonpsychiatric context in another of the five campuses
that make up New York-Presbyterian Hospital. The subsequent inquiry mushroomed
into a full investigation by the Centers for Medicaid and Medicare Services
(CMS) involving all charts at every facility making up the organization. The
study found relatively few clinical shortcomings, but many more facilities
Clinical issues were easier to address than facilities questions, explained
Susman's colleague, Philip Wilner, M.D., M.B.A., vice president and medical
director. With a time limit of only 10 days to submit a plan for correcting
the complaints, hospital officials decided not to challenge the findings and
to apply all corrections to all campuses.
Regulations applying to psychiatric facilities arrive from all directions:
CMS, the American Institute of Architects, the Joint Commission (formerly
JCAHO), HIPAA, the Drug Enforcement Administration, state and local offices of
mental health, and others. Architects and building owners must also consider
fire and electrical codes, accessibility standards, zoning laws, environmental
regulations, and energy-saving requirements.
Sometimes these were in conflict or created a second level of problems to
be solved. Electrical codes call for at least one outlet per wall, but mental
health regulations say all outlets must be tamperproof, adding to expenditures
for hardware. Patient rooms and bathrooms must allow for some privacy but
still allow the staff to know where patients are and what they are doing.
Fire codes demand corridors eight feet wide, without obstructions like
couches or chairs, even though patients often sit comfortably in the halls
where they can be seen from nursing stations.
Hospital regulations require forced-air systems pushing air out of patient
rooms and out of the building to remove infectious agents. Historically,
psychiatric spaces have not been pressurized, but CMS is now applying the rule
nationwide, said Wilner.
Program areas are now supposed to be attached to living units, under the
assumption that moving to nonadjacent areas means leaving secure space. In
addition, many off-unit areas go unused because staff members are unavailable
to move patients around the hospital.
Relocating elements such as dining spaces onto the unit calls for new
construction or renovation of space used briefly and requires thought about
how to adapt them for other uses beyond mealtimes.
The biggest expense the hospital faced was fixing what Wilner called"
ligature issues," anything solidly attached to a wall that could
be used by suicidal patients to hang themselves. Rectangular bathroom doors
were replaced with ones with round corners that can't hold a cord. Piano
hinges running the full length of doors were installed. Doorknobs shaped like
decapitated cones were installed. The few inches of water pipe running from
the wall to the washing machines in the patient laundry rooms had to be
These changes were made despite the staff's view that very few of the
suicide attempts at the Westchester site (none successful) had anything to do
with design issues.
"Removing the drawstring from patients' sweatpants would do more to
reduce the number of suicide attempts," said Susman.
There were other design issues involved, too: seclusion and restraint, the
need for program space on the unit, what to do about dropped ceilings.
In all of this, the focus of regulations was on eliminating risk and
narrowing the options for building designers, without providing much positive
guidance, said Jaques Black, president of daSILVA Architects in New York.
"But eliminating enough risk leads to the padded cell, and that's not
the way to prepare a patient for release into the outside world," said
Nevertheless, all patient-safety work to which the hospital agreed was
completed as scheduled.
The complications and the cost forced hospital officials to reevaluate
their longer-term alternatives, said Susman.
"The open issue is how do we go further to upgrade our 100-year-old
facility?" she said, in an interview. "We hope to use an approach
that balances regulatory, clinical, and patient-centered concerns in an
innovative way, but no decisions have been made yet."
Financially, their options ranged from $50 million in upgrades to a $300
million facility built from scratch—or closing the hospital altogether.
Philosophically, though, they had to balance putting lots of money into
construction versus adding staff, increasing training, and improving clinical
They decided that their priorities were to improve the quality of patient
care and increase patient safety while juggling some practical concerns.
"Major renovations made to today's standards require more common and
socializing areas," said Susman. "That puts our older dorm-style
units at risk of losing bedrooms, which in turn has fiscal
They decided to adjust the scope of corrections to different levels of
safety based on clinical data analysis and customized to their patient
population. That means that there will be ongoing discussions with regulators
to review almost every decision, but Susman and Wilner trust that they have
chosen the right path.
A truly therapeutic space has to be comfortable and safe, maintain the
dignity of patients and staff, and serve as a place for the best possible
treatment, said Susman.
"You have to emphasize patient care even in the face of ever more
stringent regulations," she said. "So you have to face up to the
regulations but also find creative solutions to conflicts by understanding the
value of the therapeutic environment." ▪