August 27, 2024 • 26 mins
Like any other healthcare facility, behavioral health environments must be comforting places to heal. But these spaces pose unique considerations to keep patients safe, requiring thoughtful balance from skilled design professionals to create environments that are beautiful and manage patient risk. Senior Interior Designer Lauren Frank, Senior Project Manager Susan Golberg, and Senior Architect Ellen Konerza are a few members of the BWBR team who work to design these facilities, and in the latest episode of Side of Design, they dive in to creating environments that prioritize safety without feeling cold or institutional.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Matthew Gerstner (00:00):
This is Side of Design from BWBR, a podcast
discussing all aspects of designwith knowledge leaders from
every part of the industry.
Hello and welcome to Side ofDesign from BWBR.
I'm your host, matt Gerstner.
On this episode, we'll bedigging into some of the unique
challenges in behavioral healthdesign, specifically finding the
balance between the risk levelof the patient population and a
(00:22):
client's unique needs and goalsfor creating a space that is
beautiful, healing and effective.
Joining the conversation fromBWBR are Lauren Frank, senior
Interior Designer, susanGoldberg, senior Project Manager
, and Ellen Canerza, seniorArchitect.
Thank you all for joining metoday.
Susan Golberg (00:41):
Thanks, Matt.
Happy to be here.
Good to be here.
Thanks for having us.
Matthew Gerstner (00:44):
I'm just going to dive right in and start with
this first question what aresome of the unique safety
considerations that come intoplay when designing for
behavioral health facilities?
Susan Golberg (00:55):
I think from studies we know that the biggest
risk in these facilities topatients are from ligature risks
, which are hanging risks, andthe locations that are the
biggest risks are in the privateareas, especially the bathrooms
and in the patient bedrooms.
So we pay particular attentionto that, Okay.
Ellen Konerza (01:16):
And I might add, just in general, what would make
a space safe for somebody whomay be in distress would be they
know where they're going.
It's clear, clear directions,they understand where the
different types of spaces arethat the patient can go, and
acoustics making sure thingsaren't too loud.
(01:37):
Anything we can do to just makea calm environment that's easy
to understand, easy to use, canincrease the safety of a space
that's easy to understand easyto use can increase the safety
of a space.
Matthew Gerstner (01:45):
That's really fascinating.
I love the ideas of trying tojust help create a serene
environment for the patients,and I'm sure there's things that
a lot of people wouldn't thinkof that can trigger someone, if
you will, in those spaces.
You're talking about sound.
You're talking about being ableto find things easily that's
(02:09):
that sounds like there's a lotof thought going into all these
little different pieces yeah,visual clutter, acoustical
clutter, spatial density, socialdensity so you don't want to
get too many people in one spaceat one time.
Susan Golberg (02:21):
That causes conflict, so you don't want to
bottleneck people.
You want to have people to havetheir enough.
Causes conflict, so you don'twant to bottleneck people.
You want to have people to havetheir enough personal space and
you also don't want to have toomany people in one area.
Okay, and then other safetythings.
You want to have securematerials.
You may want to go into that abit, and why.
Lauren Frank (02:38):
Yeah, from a finishes standpoint, we want to
make sure that they are safe forthe different areas.
So, like Susan was mentioning,for the patient bedrooms and
bathrooms, doing a higher levelof finish, things that are
seamless, that are going to beligature resistant, more
(02:59):
ligature resistant than some ofthe more public or observable
spaces, right?
Susan Golberg (03:06):
and everything's securely fastened so you can't
pull it off to have it be aweapon or you can't have a
pocket for contraband.
Same with furniture.
You don't want to have anythingfor contraband.
You don't want to havefurniture that you can pick up
and use as a weapon, or, if youcan, it's really light, you can
weight it but it's easilycleanable as well.
Lauren Frank (03:25):
Durability and cleanability is super important
in these environments.
Matthew Gerstner (03:30):
I can imagine.
So can we talk about theimportance of identifying risk
levels you know like early onand how they're used throughout
the life of a project.
Susan Golberg (03:39):
Then Sure, we start out with a floor plan and
we identify each room with adifferent risk level.
We use this to get everybody onthe same page.
We have the design team talkingwith the client, with all the
stakeholders.
We use that through the wholedesign process.
We then go through constructionwith it, so the contractors are
(04:03):
all on the same page, as wellas the authorities having
jurisdiction who do all theinspections.
It goes through that into theusers of the space and then also
it goes further into the jointcommission when they do their
surveys.
And then, ellen, you hadmentioned some yeah, so just a
(04:24):
specific scenario.
Ellen Konerza (04:25):
Recently we issued kind of an earlier set of
documents for a project.
So you know there's three tofour main design phases
throughout a project and you'regoing to cost estimate that a
few times until before it getsto construction, just to make
sure it fits with the client'sbudget.
So early on you don't have thespecifics of the type of door or
(04:47):
windows that you will in alater set of drawing.
So, you can take this diagram ifyou will.
That shows the different levelsof risk for a patient and you
can say cost estimate.
All of these bedrooms are risklevel four, for instance, so
they're going to have this typeof door or this type of wall
(05:07):
finish.
It's just an easy way toexpress the level of durability
or safety we need in theproducts without having to draw
all of that which we usually dolater in the process.
Matthew Gerstner (05:19):
I can see that being super beneficial to just
the whole process early on.
Yeah, that's that.
That's really fascinating.
Ellen Konerza (05:26):
I feel like what I've learned is the importance
of those.
We'll get into the specifics,but those level five high risk,
when a patient is just cominginto the space and they might be
agitated how important it is tothink about those spaces.
I don't think that before thisdiagram, at least, I didn't
think about them in that way.
It really helps to think ofwhat mood the patient is in in
(05:49):
these different spaces.
Matthew Gerstner (05:50):
Yeah, there's.
There's a lot going on withthis diagram.
That is just amazing,especially early on, and I can
see just so many benefits tobeing able to use this.
So can you kind of like talk usthrough the general risk levels
and how they apply in all thesedifferent spaces then?
Ellen Konerza (06:09):
There's five levels.
These come from the behavioralhealth design guide and there's
a lot of different things thatinformed this the FGI, even the
VA design guide.
But really what this this is isit's addressing the built
environment for adult inpatientmental health and behavioral
(06:30):
health unit.
It represents the leadingcurrent industry practices for
these environments and it's it'sreally just a practical means
for us to make sure the spacesare.
They protect the patients andthe staff from harm.
So this is the practicaldiagram and when you look at it
it's got five color.
Level one is the least risk, sothese are spaces where patients
(06:54):
aren't allowed.
Level five is generally adarker color.
This is kind of the high riskor kind of on.
You're unsure what type of thepatient could be agitated, or
just because they're coming intothe facility, it could be like
a seclusion space if they reallyare agitated and they need a
little bit of time to themselvesto calm down before they come
(07:15):
back into the general loungearea.
So it's a level from one tofive and then we generally
consider three, the middle of it, to be the baseline.
So this is kind of the openlounge spaces, dining areas,
usually in the middle of the thepatient housing wing or
wherever the bedrooms are, whereit's generally minimal
(07:37):
supervision.
You've got staff, kind ofeither at a desk or mingling
with patients here.
So that's, you don't need tohave the highest, the highest
safety requirements in a levelthree.
It still needs to be safe, butyou're going to see, it's
generally going to be seen if apatient is trying to tamper with
something.
Susan Golberg (07:58):
So it doesn't need to be as extreme as that
seclusion space or, yeah, anintake type of space and then
risk level four is typically thewhere they can be alone, like a
bedroom or a quiet room okay soand then we work with so there
is some criteria that's beenestablished.
That's kind of our base level.
(08:19):
That's in this guide, and thenwe work with the clients to
tailor what the criteria is foreach of these diverse levels.
Ellen Konerza (08:28):
Yeah, so that's what I was going to say is these
these are set up only for adultinpatient units.
Matthew Gerstner (08:33):
Oh, okay units .
Ellen Konerza (08:41):
It's up to us as the design team and engaging the
staff and the nursing staff andthe people actually working in
these spaces.
They need to help us understandthe patient population child
and adolescent medical careneeds, geriatric substance abuse
, eating disorders All of thesethings are on top of this kind
of baseline set of criteria thatwe need to hear from the
(09:01):
facility and the staff.
Susan Golberg (09:05):
And there's some that you know you can relax some
of it, and you know it can.
It can go both ways more strictor less strict.
We need to be able to flagthings that we think are
problematic, or you know otherthings that we think that
they'll be fine, but they needto be able to flag things that
we think are problematic orother things that we think that
they'll be fine but they need tomitigate it.
They'll figure out procedurallyhow they would mitigate
something and they would putthat in their operational
(09:26):
narrative.
Matthew Gerstner (09:28):
Okay, this, I mean this just sounds like an
incredible tool to have early on, because I did some behavioral
health work in my past as well.
So not having that and nowhearing about what's available,
this is pretty cool.
So I would have to imagine alsothat with having these
different layers or differentlevels of risk assessment, that
(09:49):
the finishes and the furnitureand that kind of thing is also
broken down then to fit intothose levels.
So then early on when you'relooking at pricing, as we were
mentioning before, you've gotsome specific items that are
kind of in those categories,that are in certain price ranges
.
Lauren Frank (10:06):
Correct, yeah.
So for level five, the highestrisk level for the walls and
floor, we would want a fullyadhered product with welded
seams, no baseboards, supercleanable surfaces and a hard
lid ceiling with ligatureresistant hardware and fixtures
yeah, and then all the way downto a level one which would be
(10:29):
standard fixtures and finishes.
Matthew Gerstner (10:31):
Okay, so something more in like the lines
of like an office type.
Lauren Frank (10:36):
Correct.
Yeah, typically our level one,our staff, only spaces, so
patients wouldn't be allowed.
But the mid level three, likeEllen and Susan were talking
about, it would really depend onhow high can the ceilings be.
Would determine the type ofceiling and fixtures that might
be used.
Yeah, of ceiling and fixturesthat might be used.
Matthew Gerstner (10:55):
Yeah.
Lauren Frank (10:55):
And floor and walls.
A little bit comes down to theclient and what their preference
would be, keeping in mind thesafety and durability and
overall calming aesthetic of thespace.
Matthew Gerstner (11:08):
That's awesome .
So then, how might these levelsbe modified by age group or
client, and do you like have anyexamples of that kind of thing?
So what Lauren was talkingabout with the ceiling heights,
for instance, age group orclient, and do you like have any
examples of that kind of thing?
Ellen Konerza (11:17):
so what lauren was talking about with the
ceiling heights.
For instance, you can imaginesomeone younger running down a
long hallway and the ceilingheight might if it's just nine
feet or something they're justrunning down easy to jump up and
pop that ceiling tile up.
So it's definitely important tothink about the age group on
(11:37):
those ceiling heights.
Geriatric patient, for instance, probably wouldn't be popping
those ceiling tiles up as easilyprobably not yeah, on pine rest
we did a lot more adultprotection.
Susan Golberg (11:51):
We had a lot more consideration on just we didn't
have any open chipboard.
We had a bigger sensory roomwith more activity kind of space
in it and you can maybe tuck itto kind of that stuff too,
maybe talk more the sensorystuff with the autism yeah, yeah
, so sensory or de-stimulationrooms, as they're sometimes
(12:13):
called, are really spaces wherea patient can go in and have
some control over the music, thelighting, any sounds, the color
.
Lauren Frank (12:25):
Sometimes we do color, changing cove, really
anything to help the patientfeel more comfortable and calm
so that they're, when they'reready, they can come out of
those rooms and join the generalmilieu in the lounge type
spaces I love the idea of thosesensory rooms.
Ellen Konerza (12:44):
Yeah, just to help de-stimulate, just calming
have you ever changed the uhfinishes or the things that you
provide in a sensory room basedon patient population?
Lauren Frank (13:03):
Yes, yeah.
So usually if it's a child andadolescent sensory or
de-stimulation room, we've donebubble tubes.
We've catered more towards whatsomeone who's younger might be
more interested in.
So I would say one example thatcomes to mind was a child and
adolescent unit and they had ade-stimulation room that had a
giant projector wall that haddifferent games and color
(13:26):
changing light activities.
It integrated with music andsound systems and there was a
higher level of acoustics inthat room just because it had
more of that active activitytype of vibe.
So for kids it's usually gearedmore towards what a kid would
be interested in.
(13:46):
And someone with autism, wemight look at fiber optics or
changing the lights, changingthe sounds, but similar things
would be done for an adultchanging the sounds, but similar
things would be done for anadult.
Usually the adult rooms haverecliners or some sort of more
calming, less active type ofactivity where you might just be
listening to sounds of nature,raindrops or birds and adjusting
(14:10):
, dimming the lights down,versus having a more color
changing, active type of spaceversus having a more color
changing active type of space.
Matthew Gerstner (14:20):
Ok, ok, so it sounds like these specific
projects have a lot of riskassociated to them.
There's a lot of opportunity orchances associated for things
to go into a negative directionpotentially, and it sounds like
you're trying to do a lot ofthings to help mitigate that
throughout the entire life ofthe project.
So you mentioned somethingspecifically like ceilings.
(14:41):
I mean, alan, you mentioned how, if it's a younger group and
they're running down the hallwayand they jump up, they could
easily pop ceilings open.
How do all these things comeinto play?
What kind of things are youdoing?
I mean, it sounds like there'sa lot of risk.
What happens if a ceiling tilepops open?
Susan Golberg (15:01):
What are we trying to prevent them from
doing?
So what happens is it presentsa ligature risk from the ceiling
grid.
So we really have to watch that.
So typically, if a ceiling is10 feet or above, we consider
that okay to use a lay-inceiling.
We really want the benefit of alarger space or a group space,
the acoustics from a lay-inceiling and if it's below that
(15:22):
height you really want a hardlid.
However, if you have in talkingwith the stakeholders, the
staff really know the patientsand their programs and if we
have a circumstance where wecan't get a 10-foot ceiling and
let's say it's 9'6", the staffmay say you know, we're fine
(15:44):
with a land ceiling here.
We think it's more importantthat we have the acoustics for
the therapeutic elements of thespace and this is supervised and
we'll take on that risk.
So we'll modify in this roomthe criteria for that risk level
.
Matthew Gerstner (16:01):
Okay, it sounds like you're engaging
staff in a lot of theseconversations early on, and so
this is just one aspect of howstaff comes into play when
you're doing these discussions.
Do they come into playthroughout it even more?
Ellen Konerza (16:17):
I was going to add, in addition to the ligature
risk, a lot of times theseproducts could be, if it's
broken off, it could be used tohurt themselves or to hurt
somebody else, or even ingested.
Or sometimes, you know, we haveto have a water fountain in
certain spaces, but somepatients drink a lot of water,
so it needs to be regulated.
(16:37):
So the only way to hear aboutthose risks are from the staff
who work with the patients inthat unit.
They're really important inevery decision that I honestly
feel, like a lot of otherprojects I've been on, it's just
you just put the water fountainthere and you don't question it
, and it's really important totalk about each specific piece
of equipment here in these typesof projects.
Matthew Gerstner (16:59):
I can absolutely see that you wouldn't
think about it as a goodcentralized location.
This is a great spot for awater fountain, but that's not
going to fly in this particularlocation.
So, with all this in mind, howdo you help clients weigh these
risks with the rewards andexplore options for design and
mitigation?
Ellen Konerza (17:17):
I really think that we, as architects of these
spaces and designers, we get tosee different projects and how
they've solved certain concernand we can share these solutions
to other clients because we'veseen it in other projects.
They could also, I guess, tourother facilities.
But right, it's a real great,baked in way throughout the
(17:40):
design of the project, to say,you know, in the beginning of
design this building took onthis shape or had this many
bedrooms.
To the end of the design, well,this project over here had this
kind of water fountain.
Let's, let's maybe try one here.
It might solve this concern.
Lauren Frank (17:56):
Well, and I think to the New York guide that gets
updated every six months to ayear.
They're constantly reviewingnew products and evaluating
their risks.
They have their own internalrisk assessment to what they're
gauging a product on, so then wecan bring that back and share
that information as well,similar to what Ellen was saying
(18:18):
, where, seeing what otherclients are doing and sharing
that information client toclient, we can also look at what
the industry is coming up with.
Different vendors areconstantly inventing and coming
up with new ligature resistantproducts that we can then bring
to our clients to have them testand give us their feedback on.
Matthew Gerstner (18:40):
That's fancy.
Is that a publication you saidthat comes out every like six
months?
Lauren Frank (18:45):
It gets updated every six months, ellen, you
might know more.
Ellen Konerza (18:50):
Yeah, it gets updated quite often.
I don't know if it's every sixmonths, but we've actually had
projects where something thatwas recommended in a past
project they've learned sincethen, may not be as safe as they
thought.
If I remember right, showercurtains come to mind, right.
That's something where theylearned a little down the road
(19:15):
that if what you're hanging itfrom can only support a certain
amount of weight, but if yougang together all of the clips,
it can support, you know, fivetimes that weight.
Susan Golberg (19:21):
so, wow, so the designs evolve, yeah, yeah and
they'll change the differentrisk levels within there too,
because it's a high, medium, lowthat they'll assign to each
product.
Matthew Gerstner (19:32):
Well, that just sounds like an invaluable
tool throughout the entireprocess.
Ellen Konerza (19:42):
The New York State Office of Mental Health.
In addition to just products,they have different blurbs in
the beginning of each section.
So in the beginning of each onethey kind of recommend as well
if you can create a shower thatdoesn't need curtains, this is
the safest way to go.
So that's a great design tip tohave.
When you're in the beginning ofdesign, you're not thinking
about curtains.
But, man, if you can have abathroom that's big enough to
also hold a shower, you're goingto be so far ahead of the game,
(20:04):
because struggling duringconstruction phase to find the
right shower curtain is reallyhard.
Matthew Gerstner (20:10):
Oh, I can imagine.
Do we want to touch on how thejoint commission surveys and
product endorsement guidelineschange over time and how that
impacts renovations as well?
Susan Golberg (20:21):
Yeah, just as we were talking about that New York
State guideline.
So the products change and theguides come out.
I think it's time to six months, I think it's just periodically
.
Every time they have productschange and you can select
something from that guide andit'll be state-of-the-art for
when the facility opens.
But a few years later the JointCommission can come through and
(20:44):
flag it.
So let's back up a minute.
So the Joint Commission doessurveys for CMS.
So if your facility wants tohave reimbursement for Medicare
or Medicaid, then you need to besurveyed by the Joint
Commission and you can sometimesfind a CMS consultant to try to
get an opinion on things.
(21:06):
But I think you just want toerr on the side of caution.
And it does, I guess, changeover time, because it used to be
that they were more considerateof if it was a supervised space
.
They put more weight on thatand I think I'm finding more and
more that even if it's asupervised space, they still
want to have ligature reducedrisk.
Matthew Gerstner (21:29):
I can imagine at the end of the construction
phase, making changes is theworst time to make changes it's
after construction, I mean it'sit's you know years later that
they come in and do theirsurveys?
Susan Golberg (21:42):
oh goodness, so it's not even you know, it's
after you.
Matthew Gerstner (21:45):
You're get your occupancy and you're in the
place and that's when they'recoming in and doing all the
surveys.
Ellen Konerza (21:51):
Well, after it's occupied and running yeah, and
it's not just you know, one roomone, it's usually all 50
bedrooms or whatever.
Susan Golberg (22:02):
Yeah, you know it's multiplied yeah, the
hardware in the store is nolonger acceptable.
You need to change them all andyou have this many weeks to be
able to do it, for this manydays to be able to do it.
Matthew Gerstner (22:12):
So, even if that was acceptable, when the
project was completedconstruction and opened, they
can come back and say that yes,that's not cheap.
Lauren Frank (22:22):
No, it's not, but it is for the benefit and safety
of the patients.
That's the flip side of thiscoin.
We want to make sure that thesespaces are safe for these
patients absolutely get it.
Matthew Gerstner (22:38):
Are they only looking at the physical
structure of the building thingsthat are built, or are they
looking deeper into how thingsoperate there too?
Ellen Konerza (22:49):
as I understand it, they're also looking at how
things operate.
Matthew Gerstner (22:53):
Okay, so that comes into play in their
recommendations and when theycome through and check things
out.
Ellen Konerza (23:00):
The nurses even use this and the joint
commission uses this diagramthey do To help feed into their.
Okay, you've got a level fivespace here.
What is in your risk mitigationplan?
If there's someone in this roomthat does X, y or Z, yeah what?
Lauren Frank (23:13):
is in your risk mitigation plan.
If there's someone in this roomthat does X, Y or Z, it's a
good diagrammatical tool to beable to say these are the
different spaces, these are therisk levels based on how the
clients have described theirpatients using them unit, so
that if the joint commissioncomes they have a diagram and
document to back up whydecisions were made and why
(23:37):
which room types are the waythey are.
Matthew Gerstner (23:40):
That's fantastic.
That sounds like something thatcan be used.
So you started out early inschematic design and you're
identifying all these differentlevels and these spaces and it's
being used all the way throughconstruction.
But then, even afterconstruction, it's still being
incorporated into the processesand how things are being run.
Lauren Frank (24:00):
Exactly.
Matthew Gerstner (24:01):
That's amazing and is it something would you
say it's like a living documentthen that if they make
renovations and changes, thenthese diagrams or the risk
assessment levels, are changingbased on what's happening in the
future, though?
Susan Golberg (24:17):
Yes, absolutely.
Matthew Gerstner (24:18):
Amazing.
So how do these negotiationsand conversations fit within
BWBR's overall philosophy andapproach to behavioral health
care design then?
Susan Golberg (24:29):
So human-centered safety is.
Bwvr's holistic, integratedapproach to behavioral safety is
priority, but not at theexpense of patient dignity and
choice.
We need to be creating atherapeutic healing environment.
We don't want it to feelpunitive or institutional.
(24:52):
We don't want to have the spacedefeat the patient before they
walk in.
Ellen Konerza (24:59):
Yeah, the not institutional and specifically
home-like, because there's a lotof safe products out there that
just look weird Like they'refrom the 70s or it's just way
oversized for what it should be.
Lauren Frank (25:15):
So making sure you're using those things
appropriately yeah, making itnot look scary or, like Susan
was saying, institutional in anyway, making it home-like and
calming and bringing nature inso that it feels really
welcoming, inviting, calming,like a place where you could get
(25:35):
better.
Susan Golberg (25:37):
And it's a balancing act.
We'll never be able to get anyplace risk-free.
We just want to try to reducethe risk.
The goal is to create acomfortable healing environment
by accommodating all of thepatient's need, but really
prioritizing safety for both thepatients and the staff.
Ellen Konerza (25:57):
And that you would want your you know a
family member.
Matthew Gerstner (26:00):
You would feel comfortable dropping off a
family member at one of thesefacilities.
Thank you all so much for yourtime and insights today it's
been a pleasure to talk to allthree of you.
Ellen Konerza (26:09):
Thank you, matt, thanks, thank you.
Matthew Gerstner (26:13):
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This is Side of Design from BWBR, a podcast
discussing all aspects of designwith knowledge leaders from
every part of the industry.
Hello and welcome to Side ofDesign from BWBR.
I'm your host, matt Gerstner.
On this episode, we'll bedigging into some of the unique
challenges in behavioral healthdesign, specifically finding the
balance between the risk levelof the patient population and a
(00:22):
client's unique needs and goalsfor creating a space that is
beautiful, healing and effective.
Joining the conversation fromBWBR are Lauren Frank, senior
Interior Designer, susanGoldberg, senior Project Manager
, and Ellen Canerza, seniorArchitect.
Thank you all for joining metoday.
Susan Golberg (00:41):
Thanks, Matt.
Happy to be here.
Good to be here.
Thanks for having us.
Matthew Gerstner (00:44):
I'm just going to dive right in and start with
this first question what aresome of the unique safety
considerations that come intoplay when designing for
behavioral health facilities?
Susan Golberg (00:55):
I think from studies we know that the biggest
risk in these facilities topatients are from ligature risks
, which are hanging risks, andthe locations that are the
biggest risks are in the privateareas, especially the bathrooms
and in the patient bedrooms.
So we pay particular attentionto that, Okay.
Ellen Konerza (01:16):
And I might add, just in general, what would make
a space safe for somebody whomay be in distress would be they
know where they're going.
It's clear, clear directions,they understand where the
different types of spaces arethat the patient can go, and
acoustics making sure thingsaren't too loud.
(01:37):
Anything we can do to just makea calm environment that's easy
to understand, easy to use, canincrease the safety of a space
that's easy to understand easyto use can increase the safety
of a space.
Matthew Gerstner (01:45):
That's really fascinating.
I love the ideas of trying tojust help create a serene
environment for the patients,and I'm sure there's things that
a lot of people wouldn't thinkof that can trigger someone, if
you will, in those spaces.
You're talking about sound.
You're talking about being ableto find things easily that's
(02:09):
that sounds like there's a lotof thought going into all these
little different pieces yeah,visual clutter, acoustical
clutter, spatial density, socialdensity so you don't want to
get too many people in one spaceat one time.
Susan Golberg (02:21):
That causes conflict, so you don't want to
bottleneck people.
You want to have people to havetheir enough.
Causes conflict, so you don'twant to bottleneck people.
You want to have people to havetheir enough personal space and
you also don't want to have toomany people in one area.
Okay, and then other safetythings.
You want to have securematerials.
You may want to go into that abit, and why.
Lauren Frank (02:38):
Yeah, from a finishes standpoint, we want to
make sure that they are safe forthe different areas.
So, like Susan was mentioning,for the patient bedrooms and
bathrooms, doing a higher levelof finish, things that are
seamless, that are going to beligature resistant, more
(02:59):
ligature resistant than some ofthe more public or observable
spaces, right?
Susan Golberg (03:06):
and everything's securely fastened so you can't
pull it off to have it be aweapon or you can't have a
pocket for contraband.
Same with furniture.
You don't want to have anythingfor contraband.
You don't want to havefurniture that you can pick up
and use as a weapon, or, if youcan, it's really light, you can
weight it but it's easilycleanable as well.
Lauren Frank (03:25):
Durability and cleanability is super important
in these environments.
Matthew Gerstner (03:30):
I can imagine.
So can we talk about theimportance of identifying risk
levels you know like early onand how they're used throughout
the life of a project.
Susan Golberg (03:39):
Then Sure, we start out with a floor plan and
we identify each room with adifferent risk level.
We use this to get everybody onthe same page.
We have the design team talkingwith the client, with all the
stakeholders.
We use that through the wholedesign process.
We then go through constructionwith it, so the contractors are
(04:03):
all on the same page, as wellas the authorities having
jurisdiction who do all theinspections.
It goes through that into theusers of the space and then also
it goes further into the jointcommission when they do their
surveys.
And then, ellen, you hadmentioned some yeah, so just a
(04:24):
specific scenario.
Ellen Konerza (04:25):
Recently we issued kind of an earlier set of
documents for a project.
So you know there's three tofour main design phases
throughout a project and you'regoing to cost estimate that a
few times until before it getsto construction, just to make
sure it fits with the client'sbudget.
So early on you don't have thespecifics of the type of door or
(04:47):
windows that you will in alater set of drawing.
So, you can take this diagram ifyou will.
That shows the different levelsof risk for a patient and you
can say cost estimate.
All of these bedrooms are risklevel four, for instance, so
they're going to have this typeof door or this type of wall
(05:07):
finish.
It's just an easy way toexpress the level of durability
or safety we need in theproducts without having to draw
all of that which we usually dolater in the process.
Matthew Gerstner (05:19):
I can see that being super beneficial to just
the whole process early on.
Yeah, that's that.
That's really fascinating.
Ellen Konerza (05:26):
I feel like what I've learned is the importance
of those.
We'll get into the specifics,but those level five high risk,
when a patient is just cominginto the space and they might be
agitated how important it is tothink about those spaces.
I don't think that before thisdiagram, at least, I didn't
think about them in that way.
It really helps to think ofwhat mood the patient is in in
(05:49):
these different spaces.
Matthew Gerstner (05:50):
Yeah, there's.
There's a lot going on withthis diagram.
That is just amazing,especially early on, and I can
see just so many benefits tobeing able to use this.
So can you kind of like talk usthrough the general risk levels
and how they apply in all thesedifferent spaces then?
Ellen Konerza (06:09):
There's five levels.
These come from the behavioralhealth design guide and there's
a lot of different things thatinformed this the FGI, even the
VA design guide.
But really what this this is isit's addressing the built
environment for adult inpatientmental health and behavioral
(06:30):
health unit.
It represents the leadingcurrent industry practices for
these environments and it's it'sreally just a practical means
for us to make sure the spacesare.
They protect the patients andthe staff from harm.
So this is the practicaldiagram and when you look at it
it's got five color.
Level one is the least risk, sothese are spaces where patients
(06:54):
aren't allowed.
Level five is generally adarker color.
This is kind of the high riskor kind of on.
You're unsure what type of thepatient could be agitated, or
just because they're coming intothe facility, it could be like
a seclusion space if they reallyare agitated and they need a
little bit of time to themselvesto calm down before they come
(07:15):
back into the general loungearea.
So it's a level from one tofive and then we generally
consider three, the middle of it, to be the baseline.
So this is kind of the openlounge spaces, dining areas,
usually in the middle of the thepatient housing wing or
wherever the bedrooms are, whereit's generally minimal
(07:37):
supervision.
You've got staff, kind ofeither at a desk or mingling
with patients here.
So that's, you don't need tohave the highest, the highest
safety requirements in a levelthree.
It still needs to be safe, butyou're going to see, it's
generally going to be seen if apatient is trying to tamper with
something.
Susan Golberg (07:58):
So it doesn't need to be as extreme as that
seclusion space or, yeah, anintake type of space and then
risk level four is typically thewhere they can be alone, like a
bedroom or a quiet room okay soand then we work with so there
is some criteria that's beenestablished.
That's kind of our base level.
(08:19):
That's in this guide, and thenwe work with the clients to
tailor what the criteria is foreach of these diverse levels.
Ellen Konerza (08:28):
Yeah, so that's what I was going to say is these
these are set up only for adultinpatient units.
Matthew Gerstner (08:33):
Oh, okay units .
Ellen Konerza (08:41):
It's up to us as the design team and engaging the
staff and the nursing staff andthe people actually working in
these spaces.
They need to help us understandthe patient population child
and adolescent medical careneeds, geriatric substance abuse
, eating disorders All of thesethings are on top of this kind
of baseline set of criteria thatwe need to hear from the
(09:01):
facility and the staff.
Susan Golberg (09:05):
And there's some that you know you can relax some
of it, and you know it can.
It can go both ways more strictor less strict.
We need to be able to flagthings that we think are
problematic, or you know otherthings that we think that
they'll be fine, but they needto be able to flag things that
we think are problematic orother things that we think that
they'll be fine but they need tomitigate it.
They'll figure out procedurallyhow they would mitigate
something and they would putthat in their operational
(09:26):
narrative.
Matthew Gerstner (09:28):
Okay, this, I mean this just sounds like an
incredible tool to have early on, because I did some behavioral
health work in my past as well.
So not having that and nowhearing about what's available,
this is pretty cool.
So I would have to imagine alsothat with having these
different layers or differentlevels of risk assessment, that
(09:49):
the finishes and the furnitureand that kind of thing is also
broken down then to fit intothose levels.
So then early on when you'relooking at pricing, as we were
mentioning before, you've gotsome specific items that are
kind of in those categories,that are in certain price ranges
.
Lauren Frank (10:06):
Correct, yeah.
So for level five, the highestrisk level for the walls and
floor, we would want a fullyadhered product with welded
seams, no baseboards, supercleanable surfaces and a hard
lid ceiling with ligatureresistant hardware and fixtures
yeah, and then all the way downto a level one which would be
(10:29):
standard fixtures and finishes.
Matthew Gerstner (10:31):
Okay, so something more in like the lines
of like an office type.
Lauren Frank (10:36):
Correct.
Yeah, typically our level one,our staff, only spaces, so
patients wouldn't be allowed.
But the mid level three, likeEllen and Susan were talking
about, it would really depend onhow high can the ceilings be.
Would determine the type ofceiling and fixtures that might
be used.
Yeah, of ceiling and fixturesthat might be used.
Matthew Gerstner (10:55):
Yeah.
Lauren Frank (10:55):
And floor and walls.
A little bit comes down to theclient and what their preference
would be, keeping in mind thesafety and durability and
overall calming aesthetic of thespace.
Matthew Gerstner (11:08):
That's awesome .
So then, how might these levelsbe modified by age group or
client, and do you like have anyexamples of that kind of thing?
So what Lauren was talkingabout with the ceiling heights,
for instance, age group orclient, and do you like have any
examples of that kind of thing?
Ellen Konerza (11:17):
so what lauren was talking about with the
ceiling heights.
For instance, you can imaginesomeone younger running down a
long hallway and the ceilingheight might if it's just nine
feet or something they're justrunning down easy to jump up and
pop that ceiling tile up.
So it's definitely important tothink about the age group on
(11:37):
those ceiling heights.
Geriatric patient, for instance, probably wouldn't be popping
those ceiling tiles up as easilyprobably not yeah, on pine rest
we did a lot more adultprotection.
Susan Golberg (11:51):
We had a lot more consideration on just we didn't
have any open chipboard.
We had a bigger sensory roomwith more activity kind of space
in it and you can maybe tuck itto kind of that stuff too,
maybe talk more the sensorystuff with the autism yeah, yeah
, so sensory or de-stimulationrooms, as they're sometimes
(12:13):
called, are really spaces wherea patient can go in and have
some control over the music, thelighting, any sounds, the color
.
Lauren Frank (12:25):
Sometimes we do color, changing cove, really
anything to help the patientfeel more comfortable and calm
so that they're, when they'reready, they can come out of
those rooms and join the generalmilieu in the lounge type
spaces I love the idea of thosesensory rooms.
Ellen Konerza (12:44):
Yeah, just to help de-stimulate, just calming
have you ever changed the uhfinishes or the things that you
provide in a sensory room basedon patient population?
Lauren Frank (13:03):
Yes, yeah.
So usually if it's a child andadolescent sensory or
de-stimulation room, we've donebubble tubes.
We've catered more towards whatsomeone who's younger might be
more interested in.
So I would say one example thatcomes to mind was a child and
adolescent unit and they had ade-stimulation room that had a
giant projector wall that haddifferent games and color
(13:26):
changing light activities.
It integrated with music andsound systems and there was a
higher level of acoustics inthat room just because it had
more of that active activitytype of vibe.
So for kids it's usually gearedmore towards what a kid would
be interested in.
(13:46):
And someone with autism, wemight look at fiber optics or
changing the lights, changingthe sounds, but similar things
would be done for an adultchanging the sounds, but similar
things would be done for anadult.
Usually the adult rooms haverecliners or some sort of more
calming, less active type ofactivity where you might just be
listening to sounds of nature,raindrops or birds and adjusting
(14:10):
, dimming the lights down,versus having a more color
changing, active type of spaceversus having a more color
changing active type of space.
Matthew Gerstner (14:20):
Ok, ok, so it sounds like these specific
projects have a lot of riskassociated to them.
There's a lot of opportunity orchances associated for things
to go into a negative directionpotentially, and it sounds like
you're trying to do a lot ofthings to help mitigate that
throughout the entire life ofthe project.
So you mentioned somethingspecifically like ceilings.
(14:41):
I mean, alan, you mentioned how, if it's a younger group and
they're running down the hallwayand they jump up, they could
easily pop ceilings open.
How do all these things comeinto play?
What kind of things are youdoing?
I mean, it sounds like there'sa lot of risk.
What happens if a ceiling tilepops open?
Susan Golberg (15:01):
What are we trying to prevent them from
doing?
So what happens is it presentsa ligature risk from the ceiling
grid.
So we really have to watch that.
So typically, if a ceiling is10 feet or above, we consider
that okay to use a lay-inceiling.
We really want the benefit of alarger space or a group space,
the acoustics from a lay-inceiling and if it's below that
(15:22):
height you really want a hardlid.
However, if you have in talkingwith the stakeholders, the
staff really know the patientsand their programs and if we
have a circumstance where wecan't get a 10-foot ceiling and
let's say it's 9'6", the staffmay say you know, we're fine
(15:44):
with a land ceiling here.
We think it's more importantthat we have the acoustics for
the therapeutic elements of thespace and this is supervised and
we'll take on that risk.
So we'll modify in this roomthe criteria for that risk level
.
Matthew Gerstner (16:01):
Okay, it sounds like you're engaging
staff in a lot of theseconversations early on, and so
this is just one aspect of howstaff comes into play when
you're doing these discussions.
Do they come into playthroughout it even more?
Ellen Konerza (16:17):
I was going to add, in addition to the ligature
risk, a lot of times theseproducts could be, if it's
broken off, it could be used tohurt themselves or to hurt
somebody else, or even ingested.
Or sometimes, you know, we haveto have a water fountain in
certain spaces, but somepatients drink a lot of water,
so it needs to be regulated.
(16:37):
So the only way to hear aboutthose risks are from the staff
who work with the patients inthat unit.
They're really important inevery decision that I honestly
feel, like a lot of otherprojects I've been on, it's just
you just put the water fountainthere and you don't question it
, and it's really important totalk about each specific piece
of equipment here in these typesof projects.
Matthew Gerstner (16:59):
I can absolutely see that you wouldn't
think about it as a goodcentralized location.
This is a great spot for awater fountain, but that's not
going to fly in this particularlocation.
So, with all this in mind, howdo you help clients weigh these
risks with the rewards andexplore options for design and
mitigation?
Ellen Konerza (17:17):
I really think that we, as architects of these
spaces and designers, we get tosee different projects and how
they've solved certain concernand we can share these solutions
to other clients because we'veseen it in other projects.
They could also, I guess, tourother facilities.
But right, it's a real great,baked in way throughout the
(17:40):
design of the project, to say,you know, in the beginning of
design this building took onthis shape or had this many
bedrooms.
To the end of the design, well,this project over here had this
kind of water fountain.
Let's, let's maybe try one here.
It might solve this concern.
Lauren Frank (17:56):
Well, and I think to the New York guide that gets
updated every six months to ayear.
They're constantly reviewingnew products and evaluating
their risks.
They have their own internalrisk assessment to what they're
gauging a product on, so then wecan bring that back and share
that information as well,similar to what Ellen was saying
(18:18):
, where, seeing what otherclients are doing and sharing
that information client toclient, we can also look at what
the industry is coming up with.
Different vendors areconstantly inventing and coming
up with new ligature resistantproducts that we can then bring
to our clients to have them testand give us their feedback on.
Matthew Gerstner (18:40):
That's fancy.
Is that a publication you saidthat comes out every like six
months?
Lauren Frank (18:45):
It gets updated every six months, ellen, you
might know more.
Ellen Konerza (18:50):
Yeah, it gets updated quite often.
I don't know if it's every sixmonths, but we've actually had
projects where something thatwas recommended in a past
project they've learned sincethen, may not be as safe as they
thought.
If I remember right, showercurtains come to mind, right.
That's something where theylearned a little down the road
(19:15):
that if what you're hanging itfrom can only support a certain
amount of weight, but if yougang together all of the clips,
it can support, you know, fivetimes that weight.
Susan Golberg (19:21):
so, wow, so the designs evolve, yeah, yeah and
they'll change the differentrisk levels within there too,
because it's a high, medium, lowthat they'll assign to each
product.
Matthew Gerstner (19:32):
Well, that just sounds like an invaluable
tool throughout the entireprocess.
Ellen Konerza (19:42):
The New York State Office of Mental Health.
In addition to just products,they have different blurbs in
the beginning of each section.
So in the beginning of each onethey kind of recommend as well
if you can create a shower thatdoesn't need curtains, this is
the safest way to go.
So that's a great design tip tohave.
When you're in the beginning ofdesign, you're not thinking
about curtains.
But, man, if you can have abathroom that's big enough to
also hold a shower, you're goingto be so far ahead of the game,
(20:04):
because struggling duringconstruction phase to find the
right shower curtain is reallyhard.
Matthew Gerstner (20:10):
Oh, I can imagine.
Do we want to touch on how thejoint commission surveys and
product endorsement guidelineschange over time and how that
impacts renovations as well?
Susan Golberg (20:21):
Yeah, just as we were talking about that New York
State guideline.
So the products change and theguides come out.
I think it's time to six months, I think it's just periodically
.
Every time they have productschange and you can select
something from that guide andit'll be state-of-the-art for
when the facility opens.
But a few years later the JointCommission can come through and
(20:44):
flag it.
So let's back up a minute.
So the Joint Commission doessurveys for CMS.
So if your facility wants tohave reimbursement for Medicare
or Medicaid, then you need to besurveyed by the Joint
Commission and you can sometimesfind a CMS consultant to try to
get an opinion on things.
(21:06):
But I think you just want toerr on the side of caution.
And it does, I guess, changeover time, because it used to be
that they were more considerateof if it was a supervised space
.
They put more weight on thatand I think I'm finding more and
more that even if it's asupervised space, they still
want to have ligature reducedrisk.
Matthew Gerstner (21:29):
I can imagine at the end of the construction
phase, making changes is theworst time to make changes it's
after construction, I mean it'sit's you know years later that
they come in and do theirsurveys?
Susan Golberg (21:42):
oh goodness, so it's not even you know, it's
after you.
Matthew Gerstner (21:45):
You're get your occupancy and you're in the
place and that's when they'recoming in and doing all the
surveys.
Ellen Konerza (21:51):
Well, after it's occupied and running yeah, and
it's not just you know, one roomone, it's usually all 50
bedrooms or whatever.
Susan Golberg (22:02):
Yeah, you know it's multiplied yeah, the
hardware in the store is nolonger acceptable.
You need to change them all andyou have this many weeks to be
able to do it, for this manydays to be able to do it.
Matthew Gerstner (22:12):
So, even if that was acceptable, when the
project was completedconstruction and opened, they
can come back and say that yes,that's not cheap.
Lauren Frank (22:22):
No, it's not, but it is for the benefit and safety
of the patients.
That's the flip side of thiscoin.
We want to make sure that thesespaces are safe for these
patients absolutely get it.
Matthew Gerstner (22:38):
Are they only looking at the physical
structure of the building thingsthat are built, or are they
looking deeper into how thingsoperate there too?
Ellen Konerza (22:49):
as I understand it, they're also looking at how
things operate.
Matthew Gerstner (22:53):
Okay, so that comes into play in their
recommendations and when theycome through and check things
out.
Ellen Konerza (23:00):
The nurses even use this and the joint
commission uses this diagramthey do To help feed into their.
Okay, you've got a level fivespace here.
What is in your risk mitigationplan?
If there's someone in this roomthat does X, y or Z, yeah what?
Lauren Frank (23:13):
is in your risk mitigation plan.
If there's someone in this roomthat does X, Y or Z, it's a
good diagrammatical tool to beable to say these are the
different spaces, these are therisk levels based on how the
clients have described theirpatients using them unit, so
that if the joint commissioncomes they have a diagram and
document to back up whydecisions were made and why
(23:37):
which room types are the waythey are.
Matthew Gerstner (23:40):
That's fantastic.
That sounds like something thatcan be used.
So you started out early inschematic design and you're
identifying all these differentlevels and these spaces and it's
being used all the way throughconstruction.
But then, even afterconstruction, it's still being
incorporated into the processesand how things are being run.
Lauren Frank (24:00):
Exactly.
Matthew Gerstner (24:01):
That's amazing and is it something would you
say it's like a living documentthen that if they make
renovations and changes, thenthese diagrams or the risk
assessment levels, are changingbased on what's happening in the
future, though?
Susan Golberg (24:17):
Yes, absolutely.
Matthew Gerstner (24:18):
Amazing.
So how do these negotiationsand conversations fit within
BWBR's overall philosophy andapproach to behavioral health
care design then?
Susan Golberg (24:29):
So human-centered safety is.
Bwvr's holistic, integratedapproach to behavioral safety is
priority, but not at theexpense of patient dignity and
choice.
We need to be creating atherapeutic healing environment.
We don't want it to feelpunitive or institutional.
(24:52):
We don't want to have the spacedefeat the patient before they
walk in.
Ellen Konerza (24:59):
Yeah, the not institutional and specifically
home-like, because there's a lotof safe products out there that
just look weird Like they'refrom the 70s or it's just way
oversized for what it should be.
Lauren Frank (25:15):
So making sure you're using those things
appropriately yeah, making itnot look scary or, like Susan
was saying, institutional in anyway, making it home-like and
calming and bringing nature inso that it feels really
welcoming, inviting, calming,like a place where you could get
(25:35):
better.
Susan Golberg (25:37):
And it's a balancing act.
We'll never be able to get anyplace risk-free.
We just want to try to reducethe risk.
The goal is to create acomfortable healing environment
by accommodating all of thepatient's need, but really
prioritizing safety for both thepatients and the staff.
Ellen Konerza (25:57):
And that you would want your you know a
family member.
Matthew Gerstner (26:00):
You would feel comfortable dropping off a
family member at one of thesefacilities.
Thank you all so much for yourtime and insights today it's
been a pleasure to talk to allthree of you.
Ellen Konerza (26:09):
Thank you, matt, thanks, thank you.
Matthew Gerstner (26:13):
This has been Side of Design from BWBR,
brought to you without any paidadvertisements or commercials.
If you found value in whatyou've heard today, give us a
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You can also reach out to us ifyou'd like to share an idea for
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Email us at sideofdesign atbwbrcom.
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