Criteria for the Design and Refurbishment of Psychiatric Acute and Intensive Care Facilities: A Statement from the Ministry of Health
Published in July 2002 by the
Ministry of Health
PO Box 5013
Wellington
New Zealand
ISBN 0-478-25510-1 (Internet)
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Acknowledgements
The Ministry wishes to thank Mr Chris Nolan, Regional Business Manager, Bay of Plenty District Health Board, for his contributions to this statement.
Contents
Purpose of this statement
Treaty of Waitangi
Introduction
Design philosophy
Design process
Design specifications
Contact
Purpose of this statement
1. This statement sets out the criteria that the Ministry of Health will use to advise District Health Boards on the design or redesign of psychiatric acute facilities. The same criteria will be used in making any recommendations to the Minister of Health about the viability of a business case for a new or upgraded psychiatric acute and intensive care facility.
2. The Ministry expects District Health Boards to provide safe and effective facilities for psychiatric acute and intensive care, so that services are consistent with the National Mental Health Strategy and the National Mental Health Sector Standard.
3. While there is no expectation that facilities should comply with a specific design brief, there are a number of principles and general requirements that are needed to achieve a safe and functional facility. If basic requirements are not met there is considerable financial risk in that expensive alterations or even replacement of relatively new facilities may be needed. Much of the content of this statement is based on lessons learned from actual examples of inadequate design and planning of New Zealand’s psychiatric acute facilities in the past.
4. This statement does not itemise or detail specific requirements under legislation such as the Building Act or fire codes, nor does it specify licensing requirements.
5. The Ministry requests that early advice is given to the Director of Mental Health about intentions to build or refurbish psychiatric acute facilities and that further reports are provided as the work progresses.
Treaty of Waitangi
6. The Government is committed to fulfilling its obligations to Mäori as a Treaty partner. The key principles that guide the fulfilment of this obligation in respect of mental health service development and delivery are:
- participation by Mäori at all levels
- partnership in service delivery
- protection and improvement of Mäori wellbeing.
Introduction
Understand the functions of psychiatric acute facilities
7. While mental health services are now largely delivered in community settings, there remains an imperative to be able to effectively treat some people with acute and intensive care needs in a highly specialised environment. Clinical leadership, skilled and dedicated staff and effective systems are the key factors for good treatment, but well-designed facilities are a necessary element in delivering effective care. Poorly designed facilities can make it more difficult to provide effective care, recruit and retain skilled staff and deliver services with a recovery focus. The Ministry of Health will seek confirmation that the functions of an acute facility have been comprehensively defined, comply with best practice and inform the architectural brief for any new facility.
Understand the needs of patients
8. Facility design may act as a tool or impediment to recovery. Essentially, facilities are for the benefit of the people who use them and must enhance their sense of dignity and comfort while promoting autonomy and ensuring safety. The onus is on all who participate in the design and building process to understand the end uses of the facility and to recognise and respect the needs of future occupants. Often the best way to ensure this is to involve people with service user experience in planning and design.
9. Many of the future occupants of psychiatric acute facilities will be detained, at least for some of the time, against their will, which makes the need for a suitable physical environment even more critical.
Design philosophy
Understand the community
10. The mental health service needs to have in place formal relationships with their local Iwi and with Pacific or other significant cultural and interest groups in the area. Ideally, this formal relationship will be supplemented by mental health staff from other cultures who can also be involved in the process of design and establishment of a new facility.
Understand the task
11. The building design of acute facilities reflects an underlying philosophy of care that is enshrined in the Mental Health (Compulsory Assessment and Treatment) Act 1992. This is essentially about achieving a balance between protecting the rights of service users and ensuring safety. It is important to consider the least restrictive treatment and support options within an acute and intensive care environment.
12. A truly functional environment is achieved by integrating the overlapping functions of clinical, service user, operational and environmental aspects of service delivery, based on an understanding of best practice and recovery.
13. The facility design needs to accommodate:
| Privacy for patients | Support for clinical functions and observation |
| Safety and security for patients | Safety and security for staff |
| Domestic scale (homeliness) | Welcoming public spaces |
| Domestic feel | Durable materials |
| Least restrictive environment | Secure space for detainment |
| Gender safe, age safe, culture safe places | Space for inclusive social interactions |
| Retreat/ sanctuary | Choice of spaces for different activities |
| Autonomy | Sense of belonging |
| Specifically designed intensive care facilities | Flexible spaces |
Be clear about both current and future requirements
14. Mental health service delivery is still in the process of radical change. While large psychiatric hospitals have now been closed or downsized to retain only small specialist units, New Zealand is still establishing the extent to which its mental health services can deliver viable acute and intensive interventions in community rather than hospital settings. The benchmark of 15 acute beds per 100,000 population is realistic for current developments but attention should be given to future needs which may, for example, mean hospital care for fewer patients who have more intensive and individualised care needs.
15. Facilities need to be flexible enough to change their use and functionality over time; for example, there may be an expectation that the use of seclusion will reduce. However, it is important that design philosophy does not anticipate future trends at the expense of current service provision.
16. A psychiatric facility needs seclusion units that comply with legislation and standards for the safety of service users, staff and members of the public. Psychiatric acute facilities are expected to provide clinical care and secure containment for disturbed general mental health patients, and should not expect forensic services to take over this management.
17. The Ministry will seek evidence that attention has been given to researching current patterns and likely future scenarios for acute hospital usage and how they have been reflected in facility design.
Recognise constraints
18. There is a need to ensure that the quality of building materials, fittings and fixtures and the floor space is adequate for the care of sometimes very disturbed patients. At the same time, a key to the success of any building project is to be realistic about available budgets from the beginning of the project.
19. The Ministry can see some value in making cost, operational efficiency and quality comparisons across different projects. Where a proposed facility is significantly cheaper or more expensive than others and the difference cannot be readily explained by different size, location (site costs) or other factors, the Ministry may query the overall design concept or ask for a reassessment of it.
20. Site constraints need to be recognised early on. Currently, psychiatric acute facilities are sited on, or in near proximity to, general hospital sites. This has the advantage of enabling shared use of other diagnostic/treatment services as well as catering, cleaning and so on. It is also beneficial for psychiatric consultation liaison functions with other hospital services. However, there also needs to be a logical relationship between the location of acute facilities and the community teams they support, along with public transport/parking spaces that make it as easy as possible for whänau and friends to visit.
21. The Ministry of Health accepts there are site and cost constraints in all building projects. These should not override the basic design philosophy, which is aimed at assisting staff to provide quality psychiatric acute and intensive care services.
Design process
Ensure early and ongoing consultation with stakeholders
22. There should be early consultation with all stakeholders on principles of care and key priorities for design. These principles and priorities should be established at the beginning of each project, with consultation being an essential part of the overall design process. A consultative group comprising consumer, family, Iwi, clinical, managerial and administrative staff and other stakeholders should be delegated the authority to agree on these principles and priorities. It may also be necessary to consult directly with local Iwi and Pacific or other population groups that are significant in the local area.
23. The architect needs to engage in ongoing consultation with the consultative group to ensure that the design brief is thorough and true to the principles and key priorities established by the group.
24. Peer review of floor plans before progressing to working drawings is desirable.
Culturally safe places
25. There should be specially designated areas that have the protection of local Mäori kawa/protocols; for example, areas in which there is no smoking, or rooms in which shoes are not to be worn. Such areas may be multi-purpose and appropriate for whänau hui, programme activities and a place for visiting whänau to stay.
Learn from others
26. There are some psychiatric acute facilities in New Zealand that feature very good aspects of design. Seek out these aspects by discussion with the people who project-managed the building of the facilities and by sending key staff on site visits to other areas if necessary. It may be possible to access plans or use the same experienced architectural and project management firms. The Ministry can suggest people to consult and places to visit in New Zealand
27. There is also an ability to learn from other countries. While literature searches do not reveal very many articles on psychiatric acute facility design features, there is an obvious trend towards very small units (fewer than ten beds) located adjacent to, and managed by, community teams. Care needs to be taken to relate international developments to the reality of mental health service delivery in New Zealand where acute facilities are expected to provide a wide range of general and specialist (intensive/tertiary) levels of care without backup from large traditional hospitals.
Project-manage the process
28. While consultation and involvement in planning should be inclusive, it is important to ensure effective management in order to keep on time, within budget and on task.
29. Consider the desirability of having a project manager appointed separately from the main (architectural) contractor in order to ensure overall management of a project.
Design specifications
Design to promote autonomy and choice
30. The design needs to incorporate spaces where a range of daily indoor activities can be undertaken. Patients need areas where they can gather and socialise.
31. As a general guide, the Ministry of Health expects that the ratio of patients to activity spaces will be about 2 to 1 in intensive care areas. For the facility as a whole there must be ample choice of spaces to go to during the day to avoid the ‘enforced congregation’ effects of all patients clustering in say one lounge with a television or around a pool table. There also needs to be the capability for gender separation in day activity space, to ensure the needs of women are met in a safe and appropriate way.
32. Different cultural, spiritual, artistic or exercise activities can be offered as choices where sufficient discrete physical spaces are available in a facility. The provision of such activities also makes sense in facilities that cater for widely different age groups.
33. Things to consider include:
- social space that provides sanctuary for vulnerable patients
- whänau space where Mäori protocols are observed
- quiet space where people can pursue their own individual activities
- indoor exercise space where physical fitness can be maintained.
34. The psychiatric facility needs to have its own entrance, including privacy of access for people who are severely disturbed and who may be admitted under the Mental Health (Compulsory Assessment and Treatment) Act 1992.
35. For therapeutic reasons, the psychiatric facility needs adequate, well laid out, outdoor space for patient enjoyment and exercise. Secure outdoor space is also needed and must be accessible from intensive care units. Given the importance of access to the outdoors it is preferable to site psychiatric acute facilities on the ground floor of any hospital.
Design to provide privacy
36. The provision of single bedrooms either with en suites or in close proximity to gender-specific bathroom facilities has become an expectation for new or refurbished psychiatric acute facilities. This standard of facility ensures one area of privacy for patients and can also make it possible for a family or whänau member to spend time with their relative in their own room. It also means the design retains a high degree of flexibility and is more likely to remain suitable for psychiatric acute and intensive care into the future.
37. The Ministry of Health considers that physical separation of male and female bedrooms and bathrooms now needs priority consideration for both privacy and safety reasons.
38. One of the benefits of a private bedroom is that a person who is suicidal or becoming very disturbed may be able to be safely maintained in their own room without the need to escalate them into separate intensive care facilities or other more restrictive care. A single bedroom is also important for safe accommodation of a young person until a more age-appropriate placement can be made. The ability to design in annexes for groups of patients who are vulnerable is highly recommended.
39. Apart from private sleeping arrangements there is also a need to provide whänau space where more than one family can meet their relatives privately and away from the main activity hub of the facility.
40. Rooms are needed where staff members can meet individually and privately with patients. Secure facilities also need to plan for meetings with district inspectors, family court judges, district court judges and review tribunals.
41. A range of appropriately designed spaces within an acute/intensive care environment, including individual bedrooms, offers choice, autonomy and privacy, which are essential for early recovery at this level of care.
Design to support safety
42. Building and design features play an important part in supporting safe clinical practice. Some of the key design features of safe acute facilities are:
- ability to maintain a high level of observation, both sight and sound, and free access to all areas
- avoidance of blind corners and rooms that are difficult to access from the main observation areas
- flush-mounted and unbreakable fixtures and fittings that are unable to be used for self-harm
- glazing that is safe and unable to be used for self-harm
- accessible, but not overly obtrusive, alarm systems
- natural light wherever possible
- natural ventilation wherever possible
- air conditioning (temperature control) in secure areas and all seclusion rooms
- for privacy and safety of personal possessions, the use of self-lockable rooms may be considered
- adequate space (eg, in corridors) to avoid unintended or inappropriate physical contacts
- a very high standard of safety features and safety feature maintenance in all bedrooms and other areas of privacy.
43. Safe design is important throughout a psychiatric acute facility because patients are often at risk of harming themselves or others. Achieving this level of safety needs to be balanced with making the atmosphere as cheerful and inviting as possible, for instance, through pleasant colours, furnishings and some allowance for personal possessions. A ‘domestic feel’ to the environment, combined with a high level of safety, is evidence of a successful design.
44. Safe design is paramount for those areas designated for intensive care, de-escalation and seclusion rooms. The Ministry of Health expects to find fitted furnishings, access to drinking water and en suite bathroom facilities provided in these areas.
45. Rooms to be used for seclusion must be approved by the Director of Area Mental Health Services as a requirement of section 71 of the Mental Health (Compulsory Assessment and Treatment) Act 1992.
46. Provision of acute/intensive psychiatric care, whether in a separate facility or integrated into an acute care environment, must support flexible adjustment of care levels for the service user. In all environments the Ministry will seek confirmation that designs are developed with the care of the highest dependency patient in mind.
Contact
For further information or to discuss the content of this statement please contact:
Dr David Chaplow
Director of Mental Health
Ministry of Health
P O Box 5013
WELLINGTON
david_chaplow@moh.govt.nz
Phone: (04) 496 2304
Related information
Intensive care publications |