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 problems.

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 covered.

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 Black.

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 work.

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 implications."

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." ▪