The Secure Residential Psychiatric Facility: Process, Design, and Results for Behavioral Healthcare

Departing the Compound, by Elzie Golden, pastel on paper, Iraq, 2005.

Art: Courtesy of the Army Art Collection, US Army Center of Military History

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 The Secure Residential Psychiatric Facility: Process, Design, and Results for Behavioral Healthcare

Chapter 16
THE SECURE RESIDENTIAL
PSYCHIATRIC FACILITY: PROCESS,
DESIGN, AND RESULTS FOR
BEHAVIORAL HEALTHCARE
Marc Alexander Shaw, AIA*

INTRODUCTION

THE CHALLENGE OF BEHAVIORAL HEALTHCARE FACILITY DESIGN

PATIENT POPULATIONS

PROCESS
Design Approach, Staff Inclusion, and Project Success
Design Process and Vocabulary

DESIGN STRATEGIES
Building Components, Engineering Systems, and Operations
Building Organization
Security
Residential Treatment Spaces
Toilets, Baths, and Showers
Therapeutic Spaces
Administrative, Public, and Support Spaces
Finishes
Furniture

SUMMARY

*Principal, Marc Shaw, Architect, LLC, 1031 North Manchester Street, Arlington, Virginia 22205

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Forensic and Ethical Issues in Military Behavioral Health

INTRODUCTION

Behavioral healthcare providers provide care. Ar- the organizational level and sometimes at the facility
chitects, engineers, and contractors make buildings. level. These in-house groups typically understand that
Effectively integrating the expertise of those who meaningful, appropriate, and effective participation
provide, support, and receive behavioral healthcare by caregivers and other facility users is central to the
services with the efforts of those who design and con- success of a given project. To that end, it is useful for
struct the facilities is vital to developing a high quality, those involved in providing care to have a basic un-
efficient, and effective facility that supports care and derstanding of the issues to be addressed, processes,
healing. Making the most of the process that results in terminology, and approaches associated with the
a new or renovated forensic facility is, therefore, cru- design and construction process.
cial. Decisions made and opportunities captured—or This chapter provides an overview of the challenges
missed—will affect patient quality-of-care, medical of secure psychiatric facility design, an introduction to
outcomes, staff quality-of-life, and facility operational the design process, and suggestions on how facility
efficiencies for decades after construction is complete. staff can most effectively participate in that process,
Yet most individuals involved in patient care and along with some discussion and specific examples
treatment are never involved in the design of the new regarding behavioral healthcare facility design.
or renovated facilities. If the opportunity does arise, It is intended primarily for those who are new to
it typically occurs only once or twice in a career. After the design effort and whose expertise—traditionally
the specific project is over, the lessons learned about viewed—lies elsewhere. It may also be useful as a
the process and details of facility design either fade refresher course for those who have been through the
significantly before the next opportunity or are simply process at least once and are about to receive a new
never used again. opportunity. The goal is to ensure that all individuals
Most large organizations, including the US military, working on the design or renovation of a behavioral
have in-house capability dedicated to the development healthcare facility are informed, effective, and efficient
and renovation of facilities. This capability exists at participants.

EXHIBIT 16-1
ADDITIONAL RESOURCES

Beyond the project specific team, various military and nonmilitary resources for information on the design and opera-
tion of behavioral healthcare facilities exist. Although some are within the federal government or the military, others
are state agencies or associations of caregivers with similar interests or missions. Some provide standards, or at least
preferences, for design and operation. Some do both. These standards change and evolve over time, and occasionally
conflict. They can present valuable starting points for research. Some notable sources include the following:

• Department of Defense, Unified Facilities Criteria (UFC) Design: Medical Military Facilities
(www.wbdg.org/ccb/DOD/UFC/ufc_4_510_01.pdf)
• Borden Institute, US Army Medical Department Center & School, Textbooks of Military Medicine
(www.cs.amedd.army.mil/borden/Portlet.aspx?id=82200b57-a7a4-4160-bb51-4a086dd6ccce)
• Department of Veterans Affairs, Office of Construction and Facilities Management (www.cfm.va.gov)
• Facility Guidelines Institute, Guidelines for the Design and Construction of Health Care Facilities
(www.fgiguidelines.org)
• National Institute of Building Sciences, Whole Building Design Guide
(www.wbdg.org/design/psychiatric.php)
• Joint Commission on the Accreditation of Healthcare Organizations (www.jcaho.org)
• National Association of State Mental Health Program Directors (www.nasmhpd.org)
• Individual State Mental Health Departments (listing at NASMHPD website shown above)
• The Center for Health Design (www.healthdesign.org)
• National Association of Psychiatric Health Systems (www.naphs.org)
• Design Considerations for Mental Health Facilities, American Institute of Architects Committee on Architecture
for Health, American Institute of Architects Press, 1993

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At the same time, this is not an exhaustive treatise. results associated with the District of Columbia’s Saint
The existing design support, literature, and standards Elizabeths Hospital is included at Exhibit 16-2, The
that the military brings to bear on facility develop- New Saint Elizabeths.
ment should not be undervalued. Outside resources As a simple aspirational goal, one should not put
exist that complement those assets (Exhibit 16-1, Ad- anyone in a place where he or she would not put
ditional Resources). Each project presents a unique his or her spouse, child, or family member. Anyone
set of issues, challenges, and opportunities. Finally, includes staff, patients, visitors, and the community.
the size and complexity of individual projects affect Frankly, this simple directive serves as a threshold test
both the process and the range of relevant issues. As for proposed solutions to any questions that will arise
an example, an overview of the specific process and during the design of a behavioral healthcare facility.

EXHIBIT 16-2
THE NEW SAINT ELIZABETHS

Introduction
The District of Columbia’s Saint Elizabeths Hospital is an example of how the process ideas described generically in
this chapter affected a significant, real world project. The challenges, processes, and solutions at Saint Elizabeths may
be instructive to individuals or teams embarking on their own behavioral healthcare project. The new Saint Elizabeths
is a 293-bed facility housing both forensic and civil patients. The District of Columbia’s Department of Mental Health
operates Saint Elizabeths as a recovery-based facility, and it is an integral part of the city’s overall mental health efforts.
Background and Challenges
Saint Elizabeths is the oldest federal psychiatric hospital
in the United States. Established in 1855 at the urging of
mental health advocate and pioneer Dorothea Dix, the
362-acre campus was originally known as the Govern-
ment Hospital for the Insane of the Army, Navy, and
the District of Columbia. Dix had suffered a breakdown
while living in England and was cared for by Quaker
advocates of “moral treatment.” They argued for the
intrinsic human dignity of patients and their respectful
treatment by caregivers. Dix recovered, was impressed
by her care, and wanted to import moral treatment ideas
to the United States.
Saint Elizabeths was the site of a military hospital dur-
ing the Civil War. Recovering soldiers—reluctant to say Saint Elizabeths’ Exterior at Dusk
they were staying at an asylum—used the name of the Architecture communicates values. It affects residents,
original land grant. The name stuck and became official their families, and the military and civilian community by
in 1916. The east campus was conveyed from the federal making clear the commitment to and importance of what
government to the District of Columbia in 1987, although occurs at the facility. It can also support staff recruitment,
the District continued to use and maintain both the east retention, and morale. Courtesy of Ron Solomon © 2014
and west campuses. As mental healthcare changed and
the residential population grew, Saint Elizabeths also expanded. Buildings were added for patient care, staff residence,
and research. The last major addition completed in 1959 was the John Howard Pavilion, which housed forensic patients.
As late as the early 1970s the patient census exceeded 7,000.
With evolving models of care, the introduction of drug therapies, cars, and development that allowed staff to live off
campus, and especially the deinstitutionalization movement of the 1970s, Saint Elizabeths’ population decreased dra-
matically. By 2000 the residential population was roughly 600, and the District was faced with a tremendous mismatch
between the hospital’s mission and the existing facilities. Budget realities made operating an oversized and antiquated
facility difficult. Legacy locations left programs in more than 40 buildings spread across the east and west campuses.
Aging buildings and infrastructure diverted limited resources away from the hospital’s core mission of patient care.
Deficiencies in facilities made needed improvements in care difficult or impossible, and planning efforts in the late
1990s made it clear that neither continuation of existing building usage and operations or rehabilitation of existing
facilities presented an appropriate long-term solution.
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Exhibit 16-2 continued

The reduced census, the overabundance of aged and inappropriate space, and the inability to reuse existing space ef-
fectively led to the District’s decision to create a new consolidated forensic and civil hospital. That decision included
a commitment to creating an extraordinary recovery-based facility that would communicate the importance of mental
healthcare and the value of all the city’s citizens.
Process
The Saint Elizabeths’ design and construction effort generally paralleled the process outlined in this chapter. At the
same time, as with any real world project, initial and ongoing adjustments dealt with project specific realities. An
all-day work session in December 2001 included more than 50 representatives of the Department of Mental Health,
Saint Elizabeths Hospital, the architect and its consultants, and the construction manager. Facilitated by the architect,
the effort was an important initial opportunity to establish relationships among team members. Project goals were
discussed along with methods for communication. A preliminary project schedule with milestones was established.
Anecdotally, it is worth noting that as the session started,
the beepers of hospital participants began to buzz. Center
for Medicare & Medicaid Services reviewers had arrived
on the campus. Although not unanticipated, this visit
required some staff to return to the hospital, quickly as-
signing others to represent their views in the meeting and
arranging later briefings. It also made immediately clear
the complexity of carrying out a major project requiring
significant senior staff input while still operating a large
mental health facility. The kickoff meeting also established Saint Elizabeths’ Patient Unit Panorama
a core work group to track and address overall project Proper layout allows casual observation of each patient
issues. Officially labeled the Owner/Architect/Construc- accessible door and the secure unit garden. Appropriate
tion Manager Workgroup, it was quickly dubbed the easi- finishes, careful furniture selection, and accessibility to
er-to-say “Troika.” The three-member team included leads light and the exterior help to avoid an institutional ap-
from the Department of Mental Health, the architect, and pearance. The larger unit can be subdivided into smaller
the construction manager. Ad hoc members were added communities with their own social amenities. Courtesy
as needed and the group ebbed between three and six. of Ron Solomon © 2014
Importantly, the Troika process was not responsible for
the daily minutiae of the work (although members were
intimately involved throughout design and construction). Programming and design meetings, construction meetings,
subcontractor meetings, and myriad necessary tasks occurred in parallel. The Troika was instead charged with both
stepping back to monitor and addressing project level issues. The duality of this position, a willingness and require-
ment to speak honestly and act collegially, and members with authority to take action allowed a quick and effective
response throughout design, construction, move-in, and occupancy.
Subsequently, two days of structured, facilitated brainstorming sessions provided a wide-ranging forum for input from
staff, caregivers, advocates, and residents. The emphasis was less on specific answers than on the characteristics of a
successful new hospital. A consensus formed around what was important. The goal was a light-filled, recovery-based
facility, modeling the behaviors and rhythms of the outside world, dedicated to the dignity and safety of residents,
staff, and visitors. Environmental sustainability and operational efficiency would be incorporated to focus current and
future resources on the hospital’s mission of care and recovery. That consensus was documented and shared to allow
design and operational options to be rationally evaluated against these popularly agreed upon desires.
Campus Consolidation
The consolidation addressed the inefficient dispersal of staff and programs across the campus. A dedicated subgroup
within the architect/engineer project team carried out this effort, which allowed quick response to immediate needs
without affecting the larger project timeline. The architect’s project executive and lead medical planner and the depart-
ment’s lead participated with both groups to ensure coordination and capture of decisions that would affect the larger
project. In some cases, processes and space needs identified as part of the consolidation served as a starting point for
discussion and development of long-term solutions. In effect, the consolidation effort became a training and practice
ground for hospital and department participants in what would be an enormously larger and more complex exercise for
the new building. The consolidation group looked at both reusing existing occupied space and renovating unoccupied
space. The result used a mix of both, moving operations from more than 40 buildings on the east and west campuses
to a more compact 10-building core on the east campus near the site of the new hospital building.

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In general, resident patients were left in place to mini-

mize disruption while office functions were relocated
to improve efficiency. The high costs of relocating some
specific functions like the facilities group and the medi-
cal laboratory led to these functions being left in place.
Although a greater geographic short-term consolidation
was possible, it was not justified by a disproportionate
use of capital without long-term benefit.
As noted above, the consolidation effort was carried
out in parallel with work on the larger project. Solu-
tions were short-term fixes for functions that would
relocate again. This condition argued for and produced
relatively inexpensive schemes that took advantage of
existing conditions wherever possible and minimized
new construction. The effect was to immediately improve
efficiency of the hospital’s operations, creating a more Saint Elizabeths’ Patient Room
compact and vibrant center of campus activity. “Face-lift” In patient rooms materials, furniture, and finishes can
aesthetic improvements like new paint and ceiling tiles suggest familiar residential or dorm-like living. Highly
were incorporated throughout new and existing spaces. secure windows avoid visible screens or cages. Carefully
selected furniture and door hardware help prevent bar-
Goal Setting and Programming ricade situations while allowing unobtrusive observation.
Portions of the Saint Elizabeths’ process were shaped by Courtesy of Ron Solomon © 2014
some unique characteristics of the project, the client, and
the local government structure. The District of Columbia
Department of Mental Health system included only the single large inpatient facility, with the most recent building, the
John Howard Pavilion, constructed in the late 1950s. The need for a new and different facility, therefore, came before an
owner without extensive experience in addressing that specific challenge. The first effort included developing project
goals as a starting point for design decisions. Space programming followed. Iterative meetings with every department
within the hospital occurred in tandem with regular briefings and input at the department level. This effort involved
a challenging integration with an evolving administrative and organizational plan for an intensely new model of
care. Changes in staffing levels and structure as well as operational changes from food service to laundry to materials
management to staff and resident daily schedules became
part of the conversation. Even the bed count of the facility
was unsettled at the start.
At the end, a structure and general space program were
established for a 293-bed integrated facility housing paral-
lel civil and forensic programs. A commitment was made
to make differences in treatment and facilities only where
necessary. A forensic unit would look like a civil unit and
vice versa. Administration and support would be shared.
Operations would be flexible to allow hospital use to
evolve with demand and changes in care and population.
Given the age and historic importance of Saint Elizabeths
Hospital and the ambitious program of the new facility,
the space program included some unique spaces. A small
museum provided a place to display and demonstrate
the facility’s history. A rare books room within the staff
Saint Elizabeths’ Garden with Labyrinth and Trellis medical library housed the collection of Willard White,
Accessible, observable, and controllable garden space the hospital’s second superintendent (including first edi-
provides access to nature and connection to the outside tions of Alice in Wonderland and Alice Through the Looking
world. The garden trellis and carefully spaced chairs can Glass). A 250-seat auditorium was located to support the
be used for formal therapy sessions or informal outdoor hospital, District of Columbia, and community func-
meals and other activities. A walking labyrinth supports tions with high-level acoustics and capacity for distance
contemplative healing exercise. Courtesy of Ron Solomon learning and broadcast. Historic furniture, art, and arti-
© 2014 facts dating back to the start of the hospital in 1855 are

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displayed throughout staff and public areas. Exterior greenhouses and horticultural planting rooms at the treatment
malls (eventually renamed therapeutic learning centers or TLCs) provided light, respite, and space for popular patient
training programs. Trellised arbors located at secure garden spaces between residential units were planned to support
casual use and act as locations for individual and group therapy.
The program continued to evolve during construction. Slower than anticipated development of the remainder of the
east campus led to creation of a staff and visitor cafeteria from space on the main public corridor near the auditorium. A
meditative labyrinth was added to a garden to support stress reduction and contemplative activity by staff and residents.
Government and Community Input
Community input and support were central to success. The hospital established a community-based advisory group that
included mental health advocates, community leaders, and even some detractors of the hospital’s previous operations.
This group was regularly updated and appropriate comments were incorporated into the project. Importantly, those
incorporations were shared with—and pointed out to—the group in subsequent briefings.
The District of Columbia Office of Planning and Zoning, DC’s Historic Preservation office, and community organizations
were involved throughout the project. Relationships established very early in the process and ongoing conversations
built support for a complex and often poorly understood project type. As an example, it was the discovered that the site
had received no District of Columbia zoning designation when conveyed from the federal government. This situation
required protracted discussion with the Office of Zoning, a group charged with overseeing redevelopment anywhere
in the city and understandably concerned about 180+ acres of land without designation. Concurrently, roughly 11
acres were zoned and subdivided from the site for construction of a new District emergency services center, leaving
just over 170 acres unzoned.
The result of the discussions was a “planned unit develop-
ment” designation setting development parameters for
the specific and carefully delineated area of the hospital.
The remainder of the east campus remained unzoned
pending further decisions by the District as to the direc-
tion of redevelopment. It has since become part of an
ongoing city sponsored master plan focused on revitaliza-
tion of the historic neighborhood and coordination with
the Department of Homeland Security to be housed at
the west campus.
The District also has a community-based structure of
elected advisory neighborhood commissions. These
groups serve as conduits of community sentiment on
projects and issues throughout the city. Briefings and
presentations were held at hours convenient to advisory
neighborhood commission members and residents. Saint Saint Elizabeths’ Classroom
Elizabeths was generally viewed positively as a long- Properly sized and carefully configured rooms allow
term neighbor and local employer. At the same time, a for short-term changes and long-term evolution of use.
project of this size needed to be regularly shared with Relocatable furniture supports conversion of a classroom
the community if only as a part of rumor control efforts. to group therapy or less structured instruction. Courtesy
Advisory neighborhood commission members, along of Ron Solomon © 2014
with members of the advisory group cited above, became
both advocates for the project at a local and city level and
sources of “rumor control” in the community.
Most community concerns were neither architectural nor operationally focused. Issues of construction and long-term
employment opportunities, traffic, and redevelopment of the soon-to-be unused acreage and buildings were raised. A
District-sponsored study from the Urban Land Institute looked at possibilities for the site and developed a “framework
plan” for redevelopment.
Finally, in addition to the city and neighborhood level players, work in the “Federal City” is subject to unique review
processes. These processes include both the presidentially appointed Federal Commission of Fine Arts and the National
Capital Planning Commission. Both have broad authority regarding any project that affects their areas of responsibility
or concern. Again, early meetings with staff, informal briefings and formal presentations, and appropriate responses to
suggestions and feedback led to a remarkably efficient approval effort given the size of the project. The project cleared
review with both entities in the minimum number of presentations.
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Schematic Design
An early decision to configure units “like an open hand” allows casual observation down corridors, a view of every
patient accessible door from a single point, small communities within the larger unit, and lots of natural light through-
out the unit. A desire for ready access to green areas both on and off units affected the layout and helped bring light
through otherwise long uninterrupted corridors between units. A variety of unit level configurations were developed
and tested, and the overall building layout was fit on the site. Placing two units at the forensic side and two at the
civil side avoided affecting small Navy radio buildings from World War II and reduced costs by lessening foundation
and roof areas.
The site organization was developed in general terms, including the building, parking and circulation, deliveries,
service areas, and security perimeters of varying levels. A decision to use “bioswales” (engineered areas with vegeta-
tion that absorb and hold water) to address storm water runoff reduced costs, lessened impact on the municipal storm
water system, and allowed for significant landscape at the site. A memorial to past patients was added. Throughout the
design process the construction manager provided input on the availability, schedule implications, and relative costs
of various solutions. Although the cheapest and/or fastest to implement was not always selected, it was important to
have this information available to inform decisions.
Cost estimates were prepared throughout the process and the plan adjusted. Once a budget approach was identified
and the plan was reasonably solid at the layout level, the project proceeded formally to DD.
Design Development
Deeply detailed space data sheets were developed in
meetings with users for each space type. At Saint Eliza-
beths the result was a very useful and often consulted
3-inch binder. The process was time consuming and
inevitably tedious at times. But developing and captur-
ing this information led to better discussions, improved
understanding by staff of the challenges faced, and a
buy-in on the solutions developed. Discussions ranged
from the specifics of the new cook/chill food preparation
and delivery system to how to best ensure security of
food and supply containers packed off unit and brought
onto the unit (addressed in part by a team member’s
discussion with stewards on a commercial airplane flight
about their security) to how to maintain the safety and
supervision of patients in single occupant toilets while
allowing privacy. Finish materials, furniture types, and
Saint Elizabeths’ Auditorium
locations for types of light switches, data outlets, and
Facility community activities are a necessary part of any
power outlets were identified. Some issues associated
medical facility. Amenities shared with the larger com-
with operational procedures could not be solved at the
munity can provide opportunities for education, raise
time, and they were carefully identified and assigned to
the level of utilization, and help destigmatize mental
specific staff for resolution.
healthcare. Entertainment, instruction, religious services,
Concurrently, detailed and sometimes overlapping dis- and other group functions can occur in a single properly
cussions were held regarding building engineering and equipped location. Placement outside the secure perim-
security systems. These discussions included a variety eter and a separate entry can simplify these extended
of participants as appropriate. For example, a discussion functions. Courtesy of Ron Solomon © 2014
of security systems included input by administrators,
nurses, psychiatrists, other clinicians, patient care techni-
cians, food service personnel, housekeeping, campus police, materials management, and even groundskeeping staff.
At this point the construction manager became intensely involved in planning the construction and phasing of the
work. The new building would be built on an occupied and operational site. New utilities needed to be run to serve
the new building and old ones relocated to serve some existing facilities. Issues of security, construction worker train-
ing, and monitoring tools and equipment unique to a psychiatric facility were addressed. Again, after verification of
the estimated cost and formal client signoff, the project proceeded to the next phase.
Although the District opted not to build mockups of spaces, there was extensive review and testing of patient furni-
ture. Given the size of the project, it was possible to have modifications to basic designs for beds, chairs, and other

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furniture to address staff concerns and experience. One important decision that arose from these discussions was to
avoid selecting furniture for patient areas based on the worst possible behavior that might be anticipated. As a result,
a very limited number of spaces was planned with a less attractive fit out, and the majority had much more residential
character, although carefully selected, furnishings.
Construction Documents
Documentation of the design, not atypically, takes the
largest individual chronological piece of the design effort.
At the same time, it is the least visible to facility staff. This
situation can be an issue when staff members perceive
a loss of momentum. It was aggravated at Saint Eliza-
beths when a year-long deferral of construction funding
delayed groundbreaking. Care was taken, therefore, to
regularly brief staff on the status of the work. Updates on
the work were part of regularly scheduled all-hands staff
meetings. Presentation drawings and a site and building
model developed during design were transferred to the
hospital and prominently displayed.
The owner took advantage of the delay and opted to have Saint Elizabeths’ Security Fence
a “constructability review” of the documents done. The A taut wire system, modified to eliminate barbed wire, is
review looked at both technical quality and the potential connected to closed circuit cameras and a central monitor-
challenges of assembling the work across all construc- ing station. Pressure on any wire automatically orients at
tion trades. A wholly independent group within the least one camera to view the contact point and simulta-
construction manager’s company conducted the review. neously notifies the central security station. Courtesy of
The feedback received was extremely positive and com- Ron Solomon © 2014
ments, where appropriate, were incorporated into both
the documents and the construction team’s planning.
During the construction document process, the construction manager both monitored the anticipated construction
cost versus a changing market and performed a series of cost estimates to ensure that the project as drawn stayed on
budget. In addition, the construction manager continued to provide feedback to the architecture and engineering team
about the anticipated availability, cost, and schedule impact of various material and system options.
Bidding and Construction
Construction of the roughly 453,000 gross square foot facility took roughly 44 months from start to occupancy of the main
building. This resulted in no small part because the size and complexity of the project required a phased construction
approach. Three formal phases were required with groundbreaking on December 19, 2006. Phase one provided utility
infrastructure and basic site work for the new facility along with temporary infrastructure to support a construction
site with more than 500 workers. Phase two included the vast bulk of the work, constructing the new hospital and the
site work to allow the new building to operate. The new hospital opened its doors in April 2010. Some site engineering
and parking were located at the area occupied by the existing and occupied John Howard Pavilion. Demolition of the
John Howard Pavilion was impossible until its residents could be relocated to the new hospital building. Phase three
demolished the John Howard Pavilion and completed the site work after occupancy of the new building. This effort
included primarily parking areas and landscape. A de facto phase four arose during construction. The initial plan
saved a concrete walled outdoor exercise space, The Yard, associated with John Howard and the forensic program.
Although the location was not ideal and some upgrade would be necessary, it was difficult to justify relocation of a
major program element.
Schedule delays led to increased deterioration of the existing facility. At the same time the District identified the Yard
location as the site for a national mental health memorial. The result was development of a new highly secure but far
less institutional outside activity space dubbed The Park. Located closer to the new building and with better ameni-
ties, it officially opened on May 6, 2012.
Both before and during construction, conversations were ongoing within the department and with various city agen-
cies, particularly police, medical emergency, and fire departments. It was crucial to ensure that efficient access to the
correct location was maintained for emergency and police services throughout construction. Making the permanent
switch to the new facility for these groups at the correct time on the correct day culminated a long and ongoing effort.

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Security During Construction

Every construction worker on the site was required, in addition to typical safety training, to participate in a session
on the unique realities of working on the site of a psychiatric hospital. This session included criteria and instruction
on interacting with patients and staff. In addition, a preconstruction briefing was held for the contractor’s senior
staff. The intent was to ensure that they understood the reasons for the layout and construction of the building and to
enlist them in observing the work as it was constructed. As examples, the importance of anti-ligature protection and
consistent use of tamper-resistant connectors was emphasized.
The entire construction site was isolated by a 6-foot temporary fence with a limited number of supervisable and gated
access points. Identification badges were issued and carried by all construction and supervisory personnel. All per-
sonnel were required to wear construction hardhats, safety glasses, and fluorescent vests at all times within the site to
make it easy to identify and approach individuals who should not be on site.
The entire site was fenced and patrolled and monitored during off hours. This effort, carried out by the construction
manager and contractor, was coordinated with the department’s own campus police.
Security at the New Saint Elizabeths
Access in the new facility fostered a protracted and
complex discussion. The “old” Saint Elizabeths had
included massive rings of seemingly identical keys to be
carried by senior and even line staff to provide access to
various rooms that had different security requirements
and/or had been rekeyed over the years. Loss of a key
or the termination of a worker could lead to expensive
and slow changes.
The new hospital combines a mix of electronic card ac-
cess and traditional keys. Electronic keys are combined Saint Elizabeths’ Green Roof
with staff identification badges. A highly secure central A 23,000 square foot green roof and onsite bioswales (rain
security room can monitor, track, and retrieve the activity gardens) reduce the costs of storm water management on
of an individual card or a specific door. Electronic access the site by slowing and limiting runoff to the municipal
by a given card can be disabled remotely in a matter of system while lowering construction cost. Courtesy of Ron
minutes, and the accessibility of a given space can be ex- Solomon © 2014
panded or restricted. Electronic control is typically used
at exterior doors, doors to major groups of spaces (eg, therapeutic learning centers, residential units), or high security
spaces (eg, medication rooms, computer labs, record rooms). Traditional keys are used at individual spaces such as
offices, storage rooms, and patient activity and sleeping rooms.
The project goal was to have each staff member carry no more than three keys to include the electronic key/identification
card, a large key for doors to which he or she was allowed access, and a smaller key for cabinetry. The list increased for
some staff. It proved impractical to have the necessary variety of small keys. Drug safes and similar functions needed
to be keyed separately. The number of spaces and complexity of security required some separate keying at the door
level. In all, however, the new system is greatly simplified and allows greater flexibility and monitoring.
Beyond keying of individual spaces and ubiquitous opportunities for important casual observation, the hospital also
includes more traditional and high tech security systems. The forensic/intensive side of the facility includes a clearly
delineated secure perimeter. Internally this includes a mix of building partitions and supervised “man traps,” double-
doored or gated. These penetrations of the perimeter can be controlled and supervised by staff within secure control
rooms. At the exterior a combined fence system includes no-climb and “taut-wire” fencing. The taut-wire system
identifies points where the fence is deformed by contact and (a) notifies the central security station and (b) automati-
cally reorients external closed circuit television cameras to allow remote viewing of the event.
Closed circuit television is distributed throughout the building, including each residential unit’s staff station, to allow
remote viewing of essentially the same view as that provided to the supervising staff member. Fixed panic buttons
at enclosed offices and wearable panic/staff down buttons that can be automatically located when activated increase
security for isolated staff.
To the extent possible, mechanical and electrical equipment and systems requiring maintenance are located in areas that
are both patient inaccessible and accessible to workers without entering patient areas or crossing the security perimeter.
The goal is to both significantly reduce the need to vet and then assign escorts to each worker doing maintenance in

(Exhibit 16-2 continues)

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Forensic and Ethical Issues in Military Behavioral Health

Exhibit 16-2 continued

the building and eliminate opportunities for potentially dangerous contraband items to become available to residents.
Finally, the importance of incorporating opportunities for casual and ongoing observation cannot be overstated. These
opportunities are provided throughout the building and include carefully planned sight lines throughout and windows
between spaces such as corridors and hallways to suites, gardens, offices, and activity areas. Classrooms are oriented
so that the teaching station can be seen from the corridor. Unobservable recesses are avoided, and common areas (such
as resident lunch areas) are laid out to allow a single staff member to view the entire space with his or her back to a
wall, and have a view to a corridor.
Design Outcome: Specific Solutions and Lessons Shared
The programming, design, documentation, and con-
struction of the new Saint Elizabeths Hospital produced
a solution unique to the challenges provided by the in-
dividual project. At the same time, those responses can
certainly be adopted, in whole or part, at other facilities
where they will support high quality care during and after
construction. Seemingly small items make big differences.
In addition to items mentioned elsewhere, some lessons
learned included the following:
Construction Phase Security: The entire site was fenced
and patrolled and monitored during off hours. This effort,
carried out by the construction manager and contractor,
was coordinated with the department’s campus police.
Leveraging the Gymnasium: The two gymnasiums be-
Saint Elizabeths’ Gymnasium
came prosaic but important symbols of the integration
Access to natural light reduces the need for artificial light-
of goals in the building. High secure windows provide
ing, and the accompanying utility cost, while supporting
daylight and a view to the sky at all times. The therapeutic
ongoing connection to the world outside the facility.
benefit of views to the exterior is appreciated along with
Courtesy of Ron Solomon © 2014
the capacity of natural light to help patients regulate their
internal biological clocks. Sunlight also makes the gyms
fully useable for the vast majority of the day without artificial lighting, satisfying goals for sustainable design and re-
ducing energy usage and utility costs. Finally, the more accessible gymnasium was offered as a potential neighborhood
amenity in off hours (with hours and uses subject to hospital approval) to maintain Saint Elizabeths’ long relationship
with the neighborhood and continue to reduce the stigma of a psychiatric facility.
Light, Views, and Access to Nature: Almost every interior corridor has natural light at both ends so that movement
is always to a lighted space and orientation while in the building is maintained. Long corridors are interrupted by
secure, accessible adjacent garden spaces. Those same spaces are visible from second floor units, offices, and corridors.
Ground level units have secure garden/activity spaces directly accessible from the community space and observable
from the central staff station. The result is an almost constant opportunity to view the natural world coupled with
ongoing casual observation of activities at these green spaces.
Site Development: The new building and parking covered more than 200,000 square feet that had previously been
grass. Even with demolition of the John Howard Pavilion and associated parking, there was significantly less area
to absorb sudden rainfall and runoff from roofs, plazas, and parking. Bioswales (mentioned in the Schematic Design
section) and a 23,000 square foot green roof slow water runoff and improve its quality. Care was taken to avoid even
small areas of temporary standing water. A memorial to past residents was developed and included a time capsule
to be opened in 50 years.
Stuff Happens: As noted above, a small staff and visitor cafeteria was added during construction when development
of accessible eateries was delayed. The hospital changed its organizational approach to populations from forensic and
civil to intensive and transitional. The exterior exercise yard was relocated and rebuilt. Saint Elizabeths was designated
as the location for a national memorial to those who had died unrecognized in mental health facilities across the United
States. Staffing and organizational changes during construction required the repurposing of spaces including the cre-
ation of a significant conference and collaborative space overlooking the main entry from what had been open plan
administrative workspace. In each case the necessary and potentially disruptive change was treated as an opportunity
to refine the design to better serve the hospital’s needs and mission.
Using the New Facility

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 The Secure Residential Psychiatric Facility: Process, Design, and Results for Behavioral Healthcare

Exhibit 16-2 continued

The process of relocating staff and residents was care-

fully planned and executed. Tours were held regularly
for both groups (as well as for outside groups such as
the Department of Veterans Affairs and the National
Building Museum). Updates on progress were shared
regularly at staff meetings. An internal contest named
the new residential units. In several cases the names of
historic buildings on the campus were used and signage
from those buildings was relocated to the new facility.
Administrative and facility staff occupied the building
ahead of patients to ensure operation of systems and fa-
miliarity with layout. Because of the abundance of space
pre-move, some staff members were reluctant to relocate
to smaller or less private workspaces. Symbolically, the
hospital chief executive officer moved to a smaller and
less private space as part of the initial move.
Saint Elizabeths’ Administration Arrival:
After much discussion, residents were relocated on a The arrival and waiting space is located outside a lockable
single day. New furniture was already installed at the door. The high glass enclosure at the stair maintains views
new facility, which simplified the relocation task. Resi- across the site and deters inappropriate or self-destructive
dents had been repeatedly informed of and prepared for behavior. The suspended artwork at the stairs, commis-
the move by staff well in advance. On moving day each sioned by the city through a competition, is installed too
resident was given a container for favorite personal effects high to be reached, and designed with resident inclusion
that he or she could choose and pack. Those containers in the design process. It is worth noting that furniture is
were relocated to the residents’ new rooms during daily periodically rearranged to meet current need.
activities and residents returned to their new units to be
greeted by their materials and donated “goodie bags”
assembled by hospital staff.
There was some real concern about the impact of major change on the patient agitation and recovery. Although hos-
pital staff and administration did report that some increase in disruptive activity occurred directly after the move,
within roughly 2 months incident levels had dropped to significantly below pre-move levels. Anecdotally, the change
is attributed to a mixture of factors including better casual observation, changed resident and staff perception of the
improved environment, layouts that allow agitated individuals to remove themselves or be guided away from conflict
situations, and higher levels of daily physical activity by residents.
During construction of the new building, Saint Elizabeths changed the basis for housing of patients. Previously, unit resi-
dency was established by program (civil or forensic). Hospital administration opted to modify this to center on the level of
care and security required for a given patient (intensive or transitional). Because the building was designed to model both
“sides” identically with similar layouts, finishes and amenities, and readily flexible levels of security, the change was eas-
ily carried out. Importantly, it also made it simpler to move staff or residency assignments across that administrative line.

THE CHALLENGE OF BEHAVIORAL HEALTHCARE FACILITY DESIGN

Inpatient behavioral healthcare facilities are funda- planning are implemented.

mentally different from acute healthcare facilities. The At an admittedly oversimplified level, traditional
unique nature of secure psychiatric facilities, including medical facilities serve high functioning, low mobility
the fact that the patients are potentially dangerous, patients who are often supervised using technological
adds another layer to that separation. Differences in monitoring. Behavioral healthcare facilities serve lower
mission, operations, and healthcare delivery affect functioning, higher mobility patients typically requir-
the site development, infrastructure, architecture, en- ing a high level of ongoing visual supervision.
gineering systems, and the therapeutic and logistical Behavioral healthcare facilities are also enormously
operation of these facilities. Although overlaps in the complex. This complexity is not often as obvious as
design of the two facility types exist, the unique and in a more traditional healthcare facility. Many of the
specific concerns of behavioral healthcare treatment issues addressed by this branch of healthcare are in-
must be considered as building design and operational terpersonal rather than technical, relative to traditional

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Forensic and Ethical Issues in Military Behavioral Health

healthcare facilities. The solutions are an integrated include both the development of the physical project
mix of technical and operational. The building becomes and the planning of its operation and long-term inter-
one tool for staff and residents to use in delivering care. actions with those who will live and work there.
In this chapter “architectural” is used to describe Architecture communicates values. People under-
the entirety of the physical facility including the stand—both consciously and intuitively—messages
bricks-and-mortar building, the engineering and other about themselves and their relationships with others
systems necessary to its operation, and the site. The in no small part because of the spaces that they occupy.
intent is to improve readability, but more importantly In the words of Winston Churchill, “We shape our
to emphasize the absolute necessity of the integration buildings and afterwards they shape us.”1 Decisions
of these systems into the whole. made during the design process are critical to com-
In the same way, “design” and “design process” municating the facility’s goals and supporting the staff
are also broadly defined for this chapter. The words and residents in achieving them.

PATIENT POPULATIONS

The basic architectural concerns noted above must systems and procedures, the differences can be a
be integrated with the unique physical and operational matter of the degree of intensity. Where this second
requirements of two specific populations. The first are condition occurs it is important to consider long-
forensic patients who are committed for evaluation or term flexibility. Security and similar requirements
treatment as a result of illegal behavior. The second will evolve based on patient population mix, short-
are high-risk patients who are committed based on term behaviors, changes in approaches to treatment,
the potential for danger to themselves or others. Al- and other factors.
though evolving legal and operational differences in Even without that inevitable evolution, the ap-
planning facilities for the two groups exist, they share propriate architectural and engineering systems and
a significant overlap in architectural and operational operational planning at a given facility will vary over
requirements. time. The anticipated length of stay and approach to
In some cases the requirements across the two treatment, the mix and acuity of patients, the legal and
populations are near enough to be considered iden- formal requirements for security and control, and the
tical, as in the case of requirements for mechanical level of flexibility required will affect the solution for
and food service systems. In cases such as security a given project.

PROCESS

Design Approach, Staff Inclusion, and Project superficially appealing, this approach can be problem-
Success atic. Even if one assumes an initial perfectly balanced
solution, a change on either side of the design demand
The creation of a high quality facility requires a equation will lead to imbalance and failure to optimally
mix of effective process and appropriate solutions. meet some crucial caregiving goal. Therefore, it is more
Both will include some combination of what has been useful to think in terms of “integration” in developing
done before and what is developed specifically for and evaluating solutions that resolve the inevitable ten-
the project at hand. Some thoughts on specific issues, sions among programmatic demands. The preferred
approaches, and space types are shared below. solution then is “both/and” rather than “either/or.”
There is a common and understandable inclination To be clear, integration in no way diminishes the
to view decisions in the design process as either/or importance of individual programmatic requirements.
propositions. As examples, patient privacy and secu- It does challenge caregivers, design professionals,
rity, patient/staff safety and patient independence, administrators, and other stakeholders to search for
dignity and observation, and comfort and ease of and create holistic solutions. Although this is a more
maintenance can seem to be at odds. They are often difficult task, the result is facilities that will operate
treated as requirements that exist in direct competition better for all those who use them, both individually
with one another. and collectively. In the end, like any military operation,
As a result, achieving “balance” among nominally the behavioral healthcare design, construction, and
conflicting demands is often cited as an approach or even operational process includes a cycle of strategy, tactics,
a solution, and especially true regarding issues of quality mission definition, execution, success, postmission
of patient experience and patient/staff safety. Although evaluation, and refinement.

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 The Secure Residential Psychiatric Facility: Process, Design, and Results for Behavioral Healthcare

User Inclusion and Integration complexity of the process and its resultant product can
vary greatly. Renovating a group of three rooms is far
It is useful to think of the project design team in different than developing a 300-bed facility.
broad terms. The term is often understood to include The process outlined below is described as neatly
only those formally trained in architecture, engineer- linear, creating a definable and useful product within a
ing, and related fields, and perhaps individuals as- fixed period via a series of discrete steps. However, like
signed to address the contractual and administrative any complex and worthwhile endeavor, it includes the
issues associated with the work. iterative component referenced above. That iteration,
On a behavioral healthcare project this view fails while sometimes frustrating, can provide a solution
to integrate and leverage the hands-on expertise pro- that is more integrated, better coordinated, and better
vided by clinicians, front line, housekeeping, security, adapted to new ideas and information that arise as part
facilities staff, and even resident patients, outpatients, of the process itself and are more effective in the end.
and patient families. The more constrained approach At the same time, it is important to finalize and
limits the quality of the eventual solution by failing enforce decisions wherever possible, providing a
to take advantage of the full range of knowledge and solid basis for further progress. Where physical or
expertise available. operational issues are unsettled, they should be clearly
It also ignores the crucial opportunity to build in- identified, along with the portions of the work that
stitutional and staff support for the eventual design they may affect.
solution and the operation thereof. The military is Like healthcare providers and military organiza-
inevitably and justifiably a hierarchical organization. tions, the design and construction professions have
At the same time, experience shows that appropriately their own terminology, culture, and processes. There
integrating users into the process significantly raises is no reason for healthcare providers involved in a
both the likelihood and level of buy-in relative to the design project, particularly front line staff, to become
process and the completed design. It also provides the experts in design and construction. It is useful for them
opportunity for users to build a long-term culture that to have a general understanding of the process and
embraces the best of the design at the “boots-on-the- terminology commonly used by architects, engineers,
ground” level. People are far more likely to support planners, contractors, and others involved in design
that which is done with them, rather than to them. This and construction.
does not suggest that individual process participants That process, and even the definition of individual
or even groups should expect to get everything that terms, can vary among projects. Terms are typically
they desire, which is especially true of idiosyncratic defined formally in the owner’s contract with the
requests. The process cannot be a free-for-all, and ap- architectural team and/or in standards relevant to
propriate structure is crucial. Time constraints, project construction or the project type. Shared terminology
complexity, and other issues will affect the feasibility exists that is commonly used to describe the design
and appropriate extent of the collaborative process. and construction process.
The structure to support this process can vary but The following is a very basic outline of the typical
should include the following: current chronological process and relevant terms.
Language and process may be modified by individual
• venues and methodologies for meaningful organizations and for specific projects. Telescoping,
input from a wide range of stakeholders; combination, and compression of tasks are not uncom-
• identification of a trusted and credible core mon on small, less complex, or fast track projects. No
group to consult with shareholders on a for- matter the precise process or terminology, appropriate
mal and ad hoc basis (to act as conduits for staff and user involvement is crucial throughout the
feedback and be a de facto “rumor control process, particularly in the earlier stages.
team”); and New technologies are beginning to affect the tradi-
• clear communication of the process and deci- tional design, documentation, and construction pro-
sions as the work progresses. cess. See Exhibit 16-3 for more information on building
information modeling and integrated project delivery.
Design Process and Vocabulary Formal milestone estimates and informal ongoing
discussions construction costs occur throughout the
Design is inevitably an iterative process that com- design and documentation process. See Exhibit 16-4
bines clear milestones and opportunities for formal for more information on understanding construc-
review and comment with ongoing discussion, re- tion cost. Building and system commissioning can be
finement, and documentation. At the same time, the integrated into the design and construction effort to

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Forensic and Ethical Issues in Military Behavioral Health

EXHIBIT 16-3
BUILDING INFORMATION MODELING AND INTEGRATED PROJECT DELIVERY

New design and construction process technologies are changing the historically typical process. The meaning of the
process terms is evolving with the increased use of two interrelated approaches to design, documentation, and opera-
tion of facilities. These approaches are building information modeling (BIM) and integrated project delivery (IPD).
The ongoing and evolving changes are transformative. At the time of this writing, these changes are beginning to
affect the way projects are carried out. In much the same way as electronic medical records will affect care, BIM and
IPD are expected to develop exponentially as the technology evolves and these processes become more widespread
and integrated in design, construction, and operations. At the simplest level, BIM allows the development of a digital
“proto-building” with live digital linkages among the building components. This development is more than a 3-D
computer model. The current software effectively meshes a database with the drawings. Programming and operational
data can be linked to individual spaces or components, enriching short- and long-term utility.
As an example, software allows the proto-building to be tested for “clashes,” locations where building components
conflict and prevent installation. Although not uniformly available at this point, building components (doors, win-
dows, boilers, light fixtures, furniture, etc) can have digitally associated attributes that allow the team to insert a virtual
window into the designed proto-building, rather than just a picture or symbol for a window.
BIM’s goal is better, earlier, and more accessible information. The BIM model is a tool shared across the owner/archi-
tect/constructor team. The result is first, the ability to understand and test options during design, and concurrently to
produce a better coordinated basis from which the contractor can proceed most efficiently. From a practical standpoint,
it “shifts effort left” on a typical timeline of the design process outlined above. The result is that decisions can—and
must—be made earlier.
At the user level, the technologies allow three-dimensional visualization of both finished spaces and technology system
components such as piping and ductwork, which makes the implications of decisions more accessible to those not
familiar with interpreting the graphic conventions of architectural and engineering drawings.
IPD is a process that integrates the previously adjacent but often functionally and culturally isolated design, construction,
and operational teams during the design effort. This approach both allows and demands a higher level of collabora-
tion throughout the project and for significant decisions and effort to be achieved earlier in the process than has been
typical. In essence, the owner, architect, and constructor act as a single collaborative entity for the purposes of process.
After design and construction are complete, BIM and IPD represent the potential for an interactive and updatable
tool for the operation, use, and modification of the facility. In reality, at this writing, a variety of hybrid and evolving
versions are used, but there is clear movement toward increased use of these approaches.

double-check and test design decisions and ensure and simplify the programming effort. In parallel, care
compliance of the finished product with the design and/or licensing-based standards may inform and
intent. See Exhibit 16-5 for more information on the affect the design. These internal and external require-
commissioning process. ments should be identified early and incorporated with
available standards.
Programming Once vision and goals exist and ruling standards
are identified, the physical requirements of the proj-
Programming is often referred to as space program- ect can be defined. That description will include the
ming and misunderstood as simply developing a list of names, uses, sizes, and quantities for each space in
required spaces for a given project. More expansively the project. To the extent possible, individual space
and accurately, programming defines the question that requirements and the functional and proximity rela-
the project will answer. This process begins with devel- tionships between individual spaces and functional
opment of a vision, goals, and criteria for the project. groups of spaces are also documented. The program-
These factors, in turn, guide the design effort and al- ming process can also identify unique spaces relevant
low consistent and rational evaluation of alternatives. to the particular project. Although these spaces can be
Facilities and organizations, including the military, functionally driven, they can also provide opportuni-
often have design standards that address requirements ties to celebrate the history or culture of the institution
for space; building systems including heating, ventilat- and its mission. Spaces and functions complementary
ing, and air conditioning systems; and process. Used to nearby facilities and communities can share demand
appropriately, these standards can significantly shorten and increase utilization and efficiency.

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 The Secure Residential Psychiatric Facility: Process, Design, and Results for Behavioral Healthcare

EXHIBIT 16-4
UNDERSTANDING CONSTRUCTION COST

Determining and monitoring project cost can be a complex effort, which is further complicated by the effects of design
decisions on operational costs (eg, less insulation may save money initially but will raise energy costs for years). Better
early planning can be more complex and raise the overall project costs with operational benefits later. Enormous effort
can go into quantifying and verifying those factors and they can seem—and in fact are—sometimes overwhelming to
those outside the design and construction community.
Simply understood, however, military healthcare projects must typically be constructed within some essentially fixed
budget. At the macro level it is useful to understand construction cost issues in terms of a simple algebraic formula:

Cost = Scope x Complexity x Quality

This approach does not require intimate knowledge of material or labor costs, markups, owner and contractor con-
tingencies, and the like. It does provide the members of the behavioral healthcare team a framework to discuss costs
and changes in an evolving design. Keeping this simple formula in mind can help avoid significant cost increases that
arise from “scope creep,” the accumulation of seemingly insignificant changes, and can suggest reducing a counter-
balancing item(s) in a fixed-price scenario.
Changing any factor in the equation above requires one or more of the others to change. It is not possible to increase
scope, quality, or complexity without affecting cost and/or reducing another factor. Increasing the scope, quality, or
complexity of the work will—all other things equal—cost more. Reducing the scope, quality, or complexity can allow
an appropriate increase in one or both of the others and/or a decrease in cost.
Formal estimates of probable construction cost are typically prepared at project milestones. If the estimate exceeds
available fixed funding, a “value engineering” exercise can identify changes that will realign the work with the budget.
This exercise can be disruptive, time consuming, and disappointing because one or more of the scope, complexity,
and quality is reduced. Although sometimes difficult, it is preferable to monitor and align decisions with the available
construction budget as decisions are being made.
Finally, design and construction contingencies are amounts typically held separate from the construction budget, and
they are used to account for the uncertainties inherent in the earlier stages of design and changes that may be required
during construction. These allowances can sometimes be reduced as design or construction proceeds and the level of
uncertainty decreases.

If applicable, the program addresses the building should still be reviewed during the remainder of
site. This definition can include built elements such design for applicability to the individual project and
as gardens, plazas, greenhouses, and parking along layout.
with infrastructure issues such as access from adjacent Finally, programming should identify external
roadways and public transit, and the availability and stakeholders whose inclusion may be useful or neces-
adequacy of utilities such as water, power, natural gas, sary to success including local government planning
solar, and telecommunications. boards, review agencies, police or fire departments,
Programming identifies and documents at least advocacy groups, state or local highway or transporta-
preliminary requirements and approaches for engi- tion groups, and local utilities.
neering systems, along with other legal or operational
requirements for the facility. These requirements Schematic Design
and approaches may include approaches to heat-
ing, ventilating, and air conditioning; food service; Schematic design (SD) lays out the basic organiza-
materials management; and other patient and staff tion of the building and site. It provides evaluation
services, along with functional relationships with and approval of that general organization. It shows
outside communities, educational institutions, or the size and shapes of rooms and their arrange-
local governments. ment in the building along with the overall building
Detailed programs may have room level data in- configuration. Some more detailed development of
cluding finishes, the location and types of engineering significant or complex internal spaces and of the
services, equipment and furniture lists, and basic and general external appearance of the building should
special engineering requirements. These decisions be available.

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EXHIBIT 16-5
BUILDING COMMISSIONING

Commissioning (sometimes abbreviated Cx) is a process that seeks to optimize the technical assembly and performance
of building systems during design, test and verify optimal assembly and performance during and after construction,
and correct operational shortcomings. It is typically carried out by a specialized entity independent of the design and
construction teams and formalizes and expands on traditional quality assurance procedures. Most often, the focus is
on the design and operation of engineering systems.
Ideally, commissioning is incorporated throughout the design and construction process. Sometimes it is compressed
and included only in the later stages of the effort, or focuses solely on testing and correction in the construction and
occupancy phases. The breadth and depth of the review can vary, along with the systems and components to be tested.
With the exception of facilities personnel, facility staff members are unlikely to become deeply involved in commis-
sioning. It may, however, be useful to include at least some critical care, life safety, and security items in the broader
commissioning testing and review plan before and after occupancy.

Drawings and written materials that are the SD Construction Documentation

product are—as the name implies—preliminary, and
they document progress to a point in time. They are a Construction documents create a tool for the con-
tool to allow further refinement of the ideas that will struction of the building. The decisions finalized in
become the new facility. DD are encapsulated in a mix of graphic presentation
(drawings) and written materials (specifications or
Design Development “specs”). Limited user input is required because this
phase focuses on documenting decisions already
Design development (DD) builds on the SD. The made. The product can be used to price the work, and
building layout and interior and exterior appearance it serves as the basis for construction by the builder.
are refined. The site layout is further developed. Major
elements of building engineering systems are typically Bidding and Award
laid out in a manner at least sufficient to allow sizing
of major equipment. The bidding and award process develops the work
In a programmatically and functionally complex and awards a contract for construction. Multiple
building like a secure behavioral healthcare facility, methodologies for this task include design/bid/build,
space data sheets or other approaches are developed. design/build, and various other forms of construction
These sheets are based on the project specific layout management. For the purposes of this discussion, these
and allow verification, refinement, and documentation methodologies are typically beyond the concerns of
of requirements at the individual room level. This pro- operational staff.
cess provides a focus on the minutiae of decisions that At the same time, it is worth understanding how
will have long-term impacts on the safety and opera- the work will be carried out on a given project. Imple-
tion of the building. Although sometimes tedious, the mentation methodology can affect the general process
collective development of these materials can facilitate outlined here, including the ability, manner, and rela-
deep early thinking about the design and minimize tive difficulty of making decisions or changes during
expensive and time-consuming redesign efforts later. both design and construction.
By the end of DD only a very limited number of clearly
identified issues—if any—with limited impact else- Construction
where in the project should remain unresolved.
Creation of large-scale digital or physical models The actual construction of the work is often the lon-
and life size mock-ups can be a part of the SD and DD. gest part of the overall effort. The owner and designer
These models are used to test appearance and function portion of the effort is typically referred to as construc-
of construction or spaces that are complex or will be tion administration. End user input is typically limited
repeated many times in the project. Examples include during this phase of the work. However, when work
patient rooms, offices, typical work staff stations, or takes place in or near occupied buildings, staff can
large public spaces. The process can also allow testing have valuable input on the planning of construction
of furniture layouts and construction details. relative to ongoing operations.

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 The Secure Residential Psychiatric Facility: Process, Design, and Results for Behavioral Healthcare

Behavioral healthcare facility security concerns are tion assembly. Issues that seem minor in commercial
paramount (eg, restricting patient access to contractor office space or residential construction (missing or loose
work areas, tools, and equipment). It may be worth- air duct grilles or switch plate covers, loose floor tiles,
while to require formal training for construction staff minor door hardware deficiencies, and the like) are
regarding interactions among construction personnel, major issues in behavioral healthcare patient care areas.
staff, and patients. Medical privacy requirements need One important staff-driven task in the pre-occu-
to be addressed. The typical hours of a construction pancy effort is reviewing existing and new operating
workday may need to be modified to accommodate procedures and protocols, which can be time consum-
facility activities or quiet times. Higher than normal ing, and this effort starts de facto during design. At
levels of worker security review and onsite identifica- the simplest level, reviewing the activities of a typical
tion may also be necessary and appropriate. day or week and testing multiple what-if scenarios
Site clean-up standards during and after construc- should occur.
tion are also important. Small and incidental debris
such as nails, screws, small glass pieces, metal scraps, Move-in and Occupancy
or even stones may be at worst unsightly on a typi-
cal project. At a behavioral healthcare facility debris At some point the facility takes formal possession of
is potential contraband and presents a possibility for the new construction, which often includes installation
aggressive and self-destructive behaviors. Although of furniture, fixtures, and equipment not supplied as
interior construction areas are typically cleaned fairly part of construction but necessary to operate the new
thoroughly, it is far less common for landscaped areas space. In behavioral healthcare facilities, particularly
to be treated as carefully during or after construction. in patient accessible areas, it is a good idea to plan an
Items concealed just an inch or two below the ground appropriate period for staff to test systems, including
surface are readily accessible over time. security, and become familiar with the new layout and
A similar level of concern should be applied to the relevant procedures before patients move in. Tours
selection of plant materials. Vining plants such as ivies during construction to allow staff to build familiarity
or easily broken tree limbs can be used as weapons. and comfort with new spaces should be considered.
Some common plants and their fruits such as American
Holly and Cotoneaster are mildly to severely toxic.2 Post-Occupancy
Finally, dense ground covers such as Pachysandra
are difficult to search and present a risk of contraband It is advisable to conduct reviews of the construc-
concealment and transfer. tion and operation of the facility at regular intervals
after completion. Six, 12, and 24 months are common
Pre-Occupancy milestones that allow the facility to (a) operate through
complete seasonal and budget cycles and (b) test re-
Near the end of construction a punchlist process sponses to issues arising from initial reviews. These
occurs. Punchlist is an archaic term that refers to iden- reviews should be completed in time to allow report-
tifying and documenting incomplete or substandard ing of relevant issues within equipment and material
construction, missing paperwork (such as equipment warranty periods.
warranties or technical data), and open contractual Often these review exercises focus primarily—or
issues. The process includes backchecking the comple- even solely—on the functional operation of the build-
tion and correction of those items and making a formal ing’s constructed components. They can also provide
signoff documenting that verification. Punchlisting is a structured opportunity to consider how the building
typically carried out at substantial completion of con- meets the day-to-day needs of staff and patients and
struction, typically defined as the point at which the to document those findings. Documentation can be
new work can be “used for its intended purpose.” A used locally to improve internal operations and, at
higher standard can reasonably be required in behavioral the organizational and healthcare community level,
healthcare facilities relative to what may be assumed by to inform subsequent design, construction, and op-
the building trades and others involved in the construc- erational efforts.

DESIGN STRATEGIES

The bricks and mortar is a common phrase used implies. Yet experience suggests that successful
to describe the physical result of the design process. behavioral healthcare facilities present some com-
It is a convenient misnomer because the physical mon opportunities and possess some common
product is far richer and complex than the phrase characteristics.

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Forensic and Ethical Issues in Military Behavioral Health

Building Components, Engineering Systems, and • Life safety (fire sprinkler systems, alarm sys-
Operations tems, and emergency notifications)
• Security (building and personal)
Users are familiar with the visible components of • Food service (staff, residents, patients, and
the facility. Walls, windows, floors, doors, ceilings, visitors)
and roofs are common concepts. However, a host of • Telecommunications and information
less visible building systems in the completed and technology
operational facility exists. Not all systems will be
affected by every project (particularly small-scale Points of connection and overlap exist between
renovations or where little or no work is associated these two lists. Each of the items has both physical
with the site). Staff should still be conscious of the and operational implications that will be part of the
potential number of systems to be resolved. The list design discussion. Informed input from users regard-
can seem overwhelming, but it provides clues and ing existing and anticipated operational processes and
structure that can lead to better solutions as individu- standards is crucial.
als and groups integrate needs beyond their normal
and obvious areas of responsibility. Operational Systems and Facility Operations
The unique nature of behavioral healthcare fa-
cilities can require greater capacity at systems than Operations of the new or renovated facility are al-
might initially be proposed. As examples, evacuating most certain to require development of new procedures
and appropriately relocating residents and staff is and modifications to existing ways. At the very least,
extremely difficult and some residents may be unable existing standards and procedures should be reviewed
to self-regulate body temperature due to medication. relative to the new configuration. On larger projects
The result is that higher levels of air conditioning and this task may require a dedicated team and a significant
emergency power are likely required in terms of both amount of time during both design and pre-occupancy.
quantity and duration. Tasks as mundane as delivering meals and linens or
A listing of significant basic systems/issues for a as high risk as building evacuation or staff support in
behavioral healthcare facility may reasonably include assaultive situations should be considered. Seemingly
the following: minor items, such as changes in availability of backup
keys or the travel distances between activities, stor-
Exterior to and Serving the Facility age, and support staff, can have real consequences on
operations, particularly in emergencies or when events
• Onsite development (landscape, storm water occur outside fully staffed hours. An informal approach
management, roads, and parking) can be as simple as reviewing the typical 24-hour day’s
• Utilities (water, sewer, natural gas, fuel oil, activities in a given space (eg, a patient unit) and then
electricity, Internet, telephone, cable, etc) doing the same for worst case scenarios. Workdays,
• Site amenities (formal and informal outdoor weekends, and holidays should be included.
activity, recreational, and public spaces) Patients with both behavior issues and significant
• Public access (patient and visitors, law en- medical needs present a unique challenge. How and
forcement, fire and emergency services) where will sick or injured residents be treated? Af-
• Integration with public transport systems and ter acute treatment is complete, can the patients be
roadways appropriately and safely returned to the behaviors
• Onsite and perimeter security (physical, tech- and potential tumult of a typical residential unit?
nological, and human) This issue is particularly relevant to postoperative
patients (eg, postappendectomy or those with casted
Integrated in the Building limbs) and those with nominally controlled but easily
communicable conditions (eg, methicillin-resistant
• Building materials (structural, enclosure, and staphylococcus aureus or tuberculosis). It may be that
partition systems; interior/exterior finishes) the solution is extended stays outside the facility. That
• Mechanical (heating, ventilation, and air con- approach, however, results in a significant staffing
ditioning systems, equipment, and controls) impact to address 24-hour off-site security and treat-
• Plumbing (systems, equipment, and controls) ment requirements.
• Electrical power (systems, equipment, and The same concerns apply to building engineering
controls; emergency power) systems. Facilities and food service staff may be deal-
• Electrical lighting (systems, equipment, and ing with new and unfamiliar systems and processes.
controls) Even if there is initial comfort, new layouts require a

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 The Secure Residential Psychiatric Facility: Process, Design, and Results for Behavioral Healthcare

backcheck of existing procedures. Whatever the level of ing, intent does not matter.
change, it is important to allow the necessary resources A strong relationship exists between building orga-
and time for sharing the new information. Formal nization and security, and a clear definition between
training may be appropriate and necessary instruc- secure and unsecure spaces is necessary. At the facility
tional, learning, and practice time should be scheduled. level, a clearly defined secure perimeter is required.
Behavioral healthcare facilities have a slim margin The penetrations of that perimeter should be limited
for architectural and operational shortcomings. Unlike and remotely controlled so that they cannot be passed
retail establishments or commercial office buildings, through with stolen keys or coerced staff. A more de-
behavioral healthcare facilities must operate fully from tailed discussion of security occurs below.
day one. On-the-job-training is a suboptimal approach. Care should be taken in locating public and quasi-
Physical modification after occupancy is difficult, public functions. It may be desirable to have an audito-
disruptive, and expensive. Walkthroughs by staff to rium outside the perimeter and administrative offices
allow reflexive familiarity with new surroundings within it even if some inconvenience to visitors or staff
can be useful. Staff tours of near complete areas before occurs. Staff and patients needing to cross the bright
move-in can identify issues and raise comfort levels line between secure and unsecure on a daily, hourly,
with changes. These tours can occur during construc- or more regular basis becomes an issue for discussion.
tion and on multiple occasions. This activity is critical Ready public access to some areas may be desirable
at patient accessible areas. even if they are used occasionally for patient activi-
ties. If this kind of use occurs, provisions for security
Building Organization sweeping and securing these areas before patient use
are necessary.
This chapter assumes that care is recovery based, At a macro level, organizing the building to afford
even for long-term forensic residents. To that end, the regular views to the outside is encouraged. These
facility architecture and operations that directly af- views may range from views of the sky through
fect residents should model and support appropriate windows looking onto secure or unsecure garden or
outside behavior to the extent possible, which includes natural spaces. These views should be carefully con-
the rhythm and the quality of daily activities. Items as sidered for issues of privacy and appropriateness and
small as eating in small groups or individually create may range from views of the sky through clerestory
a different feel to the therapeutic day. Coincidentally, windows or skylights to controlled views to the out-
they can also allow for smaller eating areas and there- side. At least some exterior spaces should be accessible
fore lower construction costs. to residents. Research supports the positive impact of
The building’s organization is often a concrete contact with nature on recovery and on the efficiency
manifestation of attitudes, policies, and organization. and morale of staff.3 Views to public space should be
Although staff familiar with “intent” may overlook un- carefully arranged to maintain patient privacy, confi-
intended messages, residents and visitors may perceive dentiality, and dignity.
them. Finish materials, furniture, and quality of space Finally, it is a challenge to collocate a behavioral
“tell” residents, staff, and visitors about the facility. At healthcare unit in a multistory acute healthcare setting.
some point architectural decisions become interwoven Besides operational issues, building layout, column
with decisions about operations and procedures. layouts, utility distribution, and other factors associ-
As an example, high security, steel-framed window ated with the “typical hospital floor” will inevitably
screens mounted inside patient accessible spaces pro- pressure the layout of the behavioral healthcare areas.
vide security, and the intention is almost positive. But Special care must be taken to maintain the unique
the appearance of these massive, institutional looking functional and experiential qualities in the behavioral
units will undercut any attempt to create a welcoming unit relative to adjacent medical units.
environment or create a community of trust between
residents and caregivers. The challenge then is to in- Security
tegrate the security requirement into the window in a
less overbearing way. Security inevitably and quickly rises to the top of
Even something as seemingly innocuous as ready concerns at behavioral healthcare facilities. By defini-
access to staff amenities can create issues. If patients tion, patients are potentially a danger to themselves
are on restricted diets and the staff coffee bar sits and others. At the same time, providing that necessary
visible in the staff station or staff drink coffee on the security can be a double-edged sword. Although pro-
unit, while charting, and so forth, a “we-and-them” viding security for staff and patients is necessary for
(or even worse—“we-versus-them”) message may be providing care, it can interfere with the effectiveness
perceived. Architecturally and therapeutically speak- of that care.

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Forensic and Ethical Issues in Military Behavioral Health

Anecdotally attributed to the founder of the Men- The issues around keying of locks, access, and
ninger Clinic, the role of the head nurse on a residential monitoring are worthy of significant discussion during
psychiatric unit was once described as being “a mother design. Easily understood, consistent, and simple-to-
in the kitchen.” The goal and imagery were—using the operate systems are likely to have higher compliance.
language of a different time—aimed at creating a safe Excessive or unwieldy security systems and inconve-
(and safe feeling) environment for the unit occupants nience can make operations impractical or inefficient,
where the important tasks of daily living and healing and they are also more likely to be bypassed by staff
could take place. Some specific approaches to support in the name of “efficiency.”
that goal include the following: Intended or not, the level of effort necessary to
operate secure doors or move around the building
• Avoid unsupervised and/or unsupervisable conveys messages about the facility, the care provided,
blind spots in units and corridors. and the staff’s attitude toward patients. The number
• Provide opportunities for casual observation of digital and physical keys carried by staff should be
consistent with a regard for patient dignity. minimized. Thought should be given about the speed
• Provide natural light and views to nature. with which electronic keys can be disarmed and locks
• Develop spaces that support activities and rekeyed if physical keys are lost or stolen, or when staff
schedules that maintain—or at least mimic members depart.
and parallel—the rhythm of the day in the As noted above, development of a continuous se-
world outside the hospital. cure perimeter is necessary at the secure facility. These
• Include places that allow staff and residents secure perimeter penetrations are typically made at
to de-escalate or avoid conflict. “mantraps” (the gender neutral but less simple to say
“person traps” having not caught on) where pairs of
A series of decisions will determine the ability of doors or gates exist in sequence and are controlled and
the facility to make working and recovering there supervised by staff, typically electronically. Doors are
safe. A reasonable and predictable level of personal controlled so that the first door/gate in a sequence
safety for staff, visitors, and patients is a prerequi- must close and secure before the second opens. Similar
site for effective care. Tools and systems are avail- “sally port” conditions exist for vehicles.
able that support this end, but they require careful Operationally, crossing the secure perimeter should
discussion and implementation. Issues include the include a review of individuals and materials. Prob-
following: lematic materials from cigarette lighters to pocket
knives to cash should remain outside the perimeter.
• personal safety systems (“staff-down” sys- Staff and visitors will need locations such as lockers
tems, phones, alarm buttons, etc); to store personal items. At the same time, these loca-
• closed circuit television with remote tions must remain under the facility’s supervision
observation; and control.
• pedestrian perimeter and internal security To the extent possible, deliveries of materials and the
including personnel traps with interlocked access and activities of maintenance personnel should
door operation; occur outside the perimeter. This location lessens the
• general traffic and delivery security including need for supervision and escorts and avoids introduc-
sally ports for vehicle control; and ing tools, delivery carts, unopened boxes, and more
• keying and access control (electronic and into the secure environment that can compromise
traditional keys, identification cards). security. Intentional and accidental introduction of
contraband is a real concern. Delivery of items such
Even the best of systems listed above are only as as food, office supplies, and linens across the perim-
effective as their operation. Systems can actually raise eter should be carefully reviewed. There is often a
risk by providing the sense that the technology itself is temptation—and even pressure—to provide “back
the solution. Procedures must therefore be developed, door” shortcuts, such as single or unsupervised doors
practiced, and enforced that support the interwoven through the perimeter for convenience. This condition
goals of security and effective care including: should be avoided. Although it seems to be “preaching
to the choir” in a military context, there is no such thing
• monitoring and response; as a secure perimeter that is “mostly secure.”
• building maintenance task access and supervi- Providing an easy route for some common, innocu-
sion; and ous activity is tempting. Care staff and administrators
• risk avoidance and de-escalation training. will find it inconvenient to travel through security

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 The Secure Residential Psychiatric Facility: Process, Design, and Results for Behavioral Healthcare

points. The argument will be made: “How bad can it be healthcare design. Although the discussion is ongoing,
if it saves dozens or even hundreds of staff hours over some recent studies have indicated that “same-hand-
time?” A single lockable door directly from (unsecure) ed” units allow for better efficiency, a quicker learning
administration to (secure) treatment areas seems at curve, and at least arguably better response times in
most a minimal risk, and even operationally efficient. crisis situations,4 which is particularly true if staff will
But in this scenario, everything and everyone in the work on or support multiple units.
administrative area are now potentially accessible Spaces for various formal and informal interaction
to patients. Everyone with even short-term access to and introspection should be available to groups and
the administrative area now has potential access to individuals. Formal therapy spaces, clinician offices,
residents and at least some secure spaces. The simple furniture groupings, and garden benches provide
answer is that a secure perimeter with even a well- unique settings for interaction. The layout should al-
intentioned gap is no longer a secure perimeter. low—and even encourage—residents to walk away
Opportunities exist to develop the new or renovated and de-escalate conflict situations on their own initia-
space that support the goals above, particularly risk tive or with staff support.
avoidance. These opportunities are general approaches Readily accessible and secure exterior green space
that extend beyond the concrete requirements of the is a tremendous asset. Residents are more likely to
facility’s architectural program. use the space if use does not require relocation by the
As a reminder of the aspirational goal proposed entire unit population. With careful planning, spaces
earlier, when dealing with security, one should not put can be configured to allow various uses from quiet
anyone in a place where he or she would not put his contemplation to gardening to recreation with minor
or her spouse, child, or family member. or no modification. Covered space to avoid sun and
rain is desirable.
Residential Treatment Spaces Any resident accessible exterior space should be
fully observable from the dedicated staff observation
Residents and direct care staff will spend the vast point mentioned above. Without that quality, staffing
majority of their time in either residential units or limitations and behavioral concerns are likely to result
therapeutic activities. It is sometimes useful to think and access to and use of this exterior space becomes
of the facility as a residential school, with residents as severely restricted. A view to a garden is nice, but if
students temporarily housed onsite in pursuit of a spe- residents are not allowed to enter it can be infuriating
cific mission through a variety of classes and activities and undermines the goal of reinforcing independence
along with more typical day-to-day activities. Again, and self-determination.
the goal is to maximize resident freedom, indepen- The adjacent garden space is the most obvious way to
dence, and dignity while maintaining and modeling bring natural light into residential spaces. The benefits
the behaviors and rhythm of the world outside the of access to exterior views and natural light on health-
hospital. Residential layouts should allow casual ob- care outcomes continue to be well documented.5 In a
servation with a view of every patient accessible door behavioral healthcare facility this access is even more
from a single controlled and consistently staffed point. important. Access to the natural variation in external
At the same time patient privacy and independence are light helps maintain the individual’s biological clock
encouraged at appropriate levels. Grouping rooms to and sense of time. (There is a reason Las Vegas casinos
create smaller communities within the larger unit can do not have windows.) In addition, that same changing
lessen a sense of institutional living. It also allows staff light and views to the exterior reinforce connection to
a method to address interpersonal conflicts and dis- the world outside the hospital, combating institution-
ruptive behaviors. A common area is useful for group alization and isolation. Particularly at residences, views
activities, but additional smaller, more intimate areas to and from the exterior should be carefully considered
associated with these smaller communities provide a both for appropriateness and to maintain patient privacy.
sense of personal and defensible territory (and model- Patient mix, acuity, behavior, and treatment require-
ing of appropriate related behaviors) and the option ments will evolve in both the short and long term. The
for concurrent dissimilar resident activities. Recesses use of the facility will therefore change over time. In
and other similar uncontrolled areas where staff and that context, the goal of the design and construction
patients are out of sight should be avoided. process is to provide a safe and flexible tool for staff to
It is common to “flip” the plans of multiple residen- leverage in supporting healing and recovery.
tial units in the same way that left and right hands are The nature of behavioral healthcare is such that a
mirror images. There is an appeal in this approach be- staff “break” while on the unit is difficult, if not impos-
cause it can help reduce the repetitive quality of much sible. The mobility of patients, the therapeutic nature

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Forensic and Ethical Issues in Military Behavioral Health

of ongoing staff/resident interactions, and the inevi- Care should be taken to prevent the possibility of
table associated stress suggest a formal and physical patients barricading themselves in rooms. As discussed
separation of ”on” and ”off” times. It is ideal to place elsewhere, this approach requires a discussion of
staff break areas readily accessible to but off the unit. door swings, hardware, keying, and furniture selec-
Staff members who are on the unit are clearly working tion, along with a method for staff emergency access
and those on break are clearly off the unit. This ap- through the patient room door or window.
proach also allows staff to securely store personal items An appropriately furnished and located visitation
and conduct personal activities away from patients, room allows family and advocates space to meet with
maintaining staff privacy and safety. Properly located, residents without entering the unit. The goal is to
these staff areas can be shared efficiently across units minimize disruption and maintain patient privacy.
and should be close enough to allow staff to quickly Ideally, the layout should allow visitors and residents
provide support in emergencies. to be quickly separated if the need arises and for visi-
Not all unit activity is structured. Formal thera- tors to be moved off the unit. If properly located, the
peutic activities, the “classes” part of the residential room can also serve as a meeting room for unit staff.
school model suggested above, are often reduced or
eliminated on weekends and evenings. At the same Toilets, Baths, and Showers
time practical everyday activities such as doing laun-
dry, watching television, playing games, reading, Although current healthcare facility standards
and relaxing are part of the therapeutic milieu. The require direct access to toilets from patient rooms, an
unit layout should allow for these activities while exception is provided for certain behavioral health-
realizing that access to some activities and equip- care facilities. That exception allows access to patient
ment may need to be restricted. As an example, a bathrooms from the corridor rather than from the
lockable laundry space with windows to the corridor room, acknowledging the need for higher levels of
and lockable door supports independent resident supervision.
activity along with ongoing observability and ap- Design of patient toilets typically includes discus-
propriate control. sion about single versus multioccupant (“gang toi-
Patient rooms are the sole private space for a let”) facilities. In the case of single occupant spaces,
resident. Single rooms have become almost a de- it may make sense to separate toilets and showers
fault approach. It is, however, worth considering to to increase turnover and utilization of spaces. The
include at least some larger rooms in the residential solution to the single versus gang toilet question may
mix. Anecdotally at least, some patients do better vary between residential and therapeutic areas as it
with a roommate. A larger room can also allow for an often does in the outside world between residential
extremely active patient to pace at night or a patient and public or commercial spaces. Multioccupant
whose physical or medical needs require extra room spaces are, by definition, less private and can feel
for equipment and staff assistance. institutional. Single occupant spaces may provide
As a matter of privacy, it is good to offset the doors more privacy and a sense of safety for the user, but
to resident bedrooms along a corridor so that they face they may also present a higher possibility of danger-
a wall rather than another door when open. This ar- ous and inappropriate behavior and be more difficult
rangement provides more privacy when patients are to casually supervise.
in their rooms and limits the possibility of disruptive Regardless of the approach chosen for the specific
behavior and inappropriate displays visible across project, these spaces should be configured, as in any
the hall. This configuration also avoids a potentially residential facility, to respect the privacy and dignity
unsafe situation where staff members standing at a of users. At the same time, doors and traffic in and out
given door have their back to another patient door should be easily observed. Doors may be locked, but
and patient. procedures to ensure safety must be in place. Spaces
Large windows that provide significant light and should be sized and equipped to allow staff to assist
views to green space are a plus. The ability to have or remove patients, if necessary.
secure natural ventilation mimics traditional residen-
tial construction. Internally mounted lockable screens Therapeutic Spaces
with an outswing window sash are one approach.
Operable windows also provide the ability to quickly Many of the design considerations associated
air out rooms if necessary without relying entirely on with residential units also apply to other therapeutic
the mechanical ventilation system that will tend to spaces. It is assumed here that the majority of formal
recirculate odors. daily therapeutic activities will take place off the unit.

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 The Secure Residential Psychiatric Facility: Process, Design, and Results for Behavioral Healthcare

Although various names exist, and culturally appropri- The secure behavioral healthcare facility may
ate naming at the facility level should be encouraged, include formal hearing or courtroom space. Telecon-
these group learning, recreational activity, and therapy ferencing technology can address time, travel, and
spaces are often referred to as treatment malls. The security concerns for judges, witnesses, and residents
mix and nature of treatment mall spaces will vary while meeting legal process requirements.6 Private
according to the facility and the project. Again, to the meeting spaces for counsel, family members, and wit-
extent possible, they should allow residents to model nesses should be included near to but outside the hear-
behavior outside the hospital. Classrooms should look ing room. A separate and secure preparation area and
like military or private sector classrooms. Lunchrooms office space directly accessible to the room for judges
should look like places that one might leave the office to and similar functionaries may be useful.
lunch. Meeting rooms should look like meeting rooms. Support spaces include functions such as materials
Careful selection of furniture and finish materials management, food service, maintenance and grounds,
can allow multiple uses for a single space if appropri- and engineering equipment areas. To the extent pos-
ate storage is provided. As an example, a cushioned sible, these spaces should be accessible without outside
floor might accommodate aerobics, cardiopulmonary personnel entering the secure facility. They should
resuscitation training, and staff instruction in safe allow—even require—the thorough review by facility
“take-down” methods for combative patients in a personnel of any materials, equipment, or supplies
single room along with more traditional meetings and entering or leaving the facility. Materials entering the
instruction. secure area from the outside world need to be vetted
There are, however, unique considerations for this before entry. The same is true of materials such as food
sort of educational facility. Capacity must be in place or linens traveling within the hospital, particularly as
to allow staff to deal with both malingerers who refuse they cross the secure perimeter or enter secure resi-
to participate and for those who—for whatever rea- dential or treatment areas.
son—cannot deal with a full day of therapeutic activi-
ties. Addressing these issues as part of the treatment Finishes
area supports operational efficiency and can reduce
required staffing. As with residential units, providing A meaningful discussion of specifics of materials
a clear delineation between therapeutic and staff break and finishes for walls, floors, ceilings, millwork, cabi-
areas is highly desirable. netry and the special needs for secure doors, external
Opportunities for ongoing casual observation and interior window glazing, flooring, ceiling systems,
should be integral to the design, which is particularly and more is beyond the scope of this chapter. There is
important at spaces such as lunchrooms, corridors, and a wealth of information and specialized information
other large group gathering and social spaces. These sources relative to components applicable to the build-
can be as simple as locations where a staff member ing type (see Exhibit 16-1).
can stand with a back to the wall and both observe the Maintainability and efficiency of operation should
entire space and make ready eye contact with a remote be integrated with aesthetic concerns in finish selec-
staff member. Vision panels at doors are useful in many tion. This approach supports flexibility and evolution
cases, although care should be taken about their use at in the facility’s appearance over time. That flexibility
offices or rooms where individual and group therapy should be a part of the design effort from the start.
occur. Functional room layouts that locate staff to be Properly planned, the updating can have little or
visible through door vision panels can increase obser- no impact on otherwise necessary operational and
vation and safety. maintenance costs. As a general rule, updating is best
achieved by recognizing during design those things
Administrative, Public, and Support Spaces that are relatively easy to change, such as paint colors,
fabrics, furniture, artwork, military command or unit
These functions typically occur outside secure displays, and even plantings. Many of these items will
residential and treatment areas, and they can often be require replacement or modification as part of neces-
configured much like similar spaces at equivalent non- sary and ongoing maintenance.
behavioral military healthcare facilities. At the same Glazing at interior and exterior windows, doors,
time, the general public and most visitors will have and vision panels should be carefully reviewed at pa-
severely limited access to residential and treatment tient accessible areas. Various forms of high strength
areas. As a result, these more publicly accessible spaces glass, laminated glass products, and polycarbonates
will often represent—to visitors and the public—the (plastics) all have their place. Scratch and yellowing
quality and character of care provided. resistant polycarbonate glazing is not as hard a surface

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Forensic and Ethical Issues in Military Behavioral Health

as glass, but it does provide significant resistance to layout. The second is less likely to be a useful weapon,
vandalism. The glazing solution should be carefully but is often unattractive and can be a barricade assist.
examined throughout because it may require discus- In either case, the level of available staff observation
sion within the team and with code review officials. while the furniture is in use can affect the appropriate
As an example, wired glass is the typical solution at solution.
fire doors that lead to exit stairs. It can, however, be Furniture in common areas or classrooms has a
broken by impact, producing broken glass pieces that relatively high level of supervision while in use. Move-
are then available to patients. able furniture may provide desired flexibility and a
preferred appearance. However, this does not prevent
Furniture selecting well-constructed and heavy furniture that
lessens the likelihood that it will become a projectile.
Furniture selection and maintenance is an issue It does allow a somewhat more residential or at least
for significant discussion. Furniture selection has a dorm-like atmosphere.
tremendous impact on how a space is perceived, and Tough, nonporous, nonabsorptive fabrics (fo-
it is an excellent opportunity to consider the integra- cused initially at the senior healthcare market)
tion of conflicting goals and desires. As a general rule, provide alternatives to shiny institutional vinyl. In
furniture finishes and design do not need to be selected any case methodologies, equipment, and materials
based on the most troublesome patient’s behavior. necessary for care of any special fabrics should be
Patients can be relocated between rooms, furniture coordinated with facility housecleaning staff along
can be moved, and different rooms and units can be with more typical furniture. Patient room furniture,
furnished differently. Accessibility to or maintenance however, has long periods of unsupervised use. In
of a more desirable environment may even serve as addition to concerns about the furniture itself, it
appropriate positive behavioral reward or reinforce- should be impossible to use the furniture to create
ment. Removing a rug or a desk chair from a disruptive a barricade situation. The immediate solution is
patient, or one who staff feels may become disruptive, often to affix the furniture to walls or floors. Aside
seems preferable to denying these simple amenities to from the perception of a room with a bed, desk, and
every residential patient. wardrobe nailed in place, one practical problem with
At the same time furniture that will be available to this approach is that it makes concealing contraband
residents should be carefully inspected and samples easier and searching a room for contraband harder.
should be aggressively tested. Furniture that can be At treatment areas, carefully selected moveable and
easily broken or disassembled is problematic. Parts stackable furniture (and related storage) can allow
such as bolts, screws, or braces that can be removed variation in the use of a given space. If scheduling
and concealed while leaving the furniture otherwise in- allows, this flexibility increases the efficiency of a
tact present a significant danger to staff and residents. building and can reduce the overall building area
Furniture that can be readily thrown, brandished in and cost of construction.
whole or part as a weapon, or used to barricade doors Finally, thought should be given to the relative ap-
also presents real concerns. Creases and deep seams pearance and selection of furniture used for similar
that can provide places for concealment or are difficult activities across the facility. Use of similar items pro-
to clean and should be avoided. motes interchangeability and simplifies maintenance.
These issues have typically been addressed by us- Where appropriate, it can signal the equality of staff
ing furniture that is either (a) secured-in-place and/or across disciplines and the relationship between staff
heavy or (b) ultra-light and/or heavily cushioned. The and residents. Yet, there are times where variation or
first option is hard to move or throw, but less flexible in hierarchy in appearance is appropriate.

SUMMARY

Developing good—and even great—facilities that the same time, no solution or building is ever perfect.
support recovery is ultimately the goal, and it is a Even if the ideal match of need and form somehow
realistic one. A collegial process that includes a clear occurs at the outset, needs and uses change. The
vision, incorporates appropriate input from knowl- evolutions of demographics, treatment modalities,
edgeable stakeholders, centers on the integration of patient mix, staff mix, funding levels, technology, and
the complex demands of care, and incorporates the dozens of other variables will reset the balance over
best of technical and creative ideas will produce a bet- time. The architect and engineer will not be there at
ter, more flexible, and more efficient end product. At two o’clock in the morning, in the snowstorm, when

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 The Secure Residential Psychiatric Facility: Process, Design, and Results for Behavioral Healthcare

the power goes out, and when a patient is in duress. expertise, and creativity into a functional, flexible,
The caregivers and the physical facility will be there, efficient, and integrated solution. That solution will
however. let staff and families provide the best possible care
With that caveat, the ideas and examples here are and the best outcomes. Successful solutions work
not presented to suggest that they are “the answer.” at multiple levels for the people who will live there
They are instead provided to support a talented and while they need to be there, and for those who care
committed group of individuals and organizations for them. That success extends well beyond the purely
as they best address an exceptionally complex, chal- functional and communicates the quality of the care
lenging, evolving, and fascinating task. Where these given and received.
ideas are appropriate, use them. Where they are not, In the end, the answer is not the building itself. The
modify them to suit the specific need. The best results building is a tool. The goal of both the design effort
will arise from a shared framework for action, making and the completed facility is the potential to provide
the best use of the knowledge, expertise, and creativity extraordinary behavioral healthcare and the positive
of all team members, and leveraging that knowledge, outcomes of that result from that care.

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