Inadequate Mental Health Facility and Space Design

Facility design is a key element of inpatient mental health safety and harm reduction. Designated inpatient stabilization and recovery programs as well as non-designated programs (e.g., general medical-surgical units and emergency departments (EDs)) should promote a treatment milieu conducive to client wellness concurrent with risk reduction for clients, staff, third parties, and the public. Inadequate facility and space design is a frequent contributing factor in HIROC claims involving harm to clients including: abuse (sexual and physical), elopement, death by suicide while in-care, self-harm, and homicides. Facility design and space considerations can positively impact and enhance the cognitive and behavioural aspects of therapeutic care.

Expected Outcomes

Adopt standardized, evidence-based guidelines for facility and space design process, and mental health environmental hazards and assessment checklist for inpatient mental health and addiction units. 

Adopt standardized, evidence-based protocols for client observation and safety processes, scheduled environmental safety assessments, and post incident response plan for at risk mental health clients.

Definitions and Acronyms

  • Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
  • ED – emergency department
  • IV – intravenous

Common Claims Themes and Contributing Factors

  • Frequently involve:
    • Anchor points such as stair railings, fixed rods or bars (e.g., shower curtain), bathroom fixtures, door handles, ceiling vents, and IV pumps;
    • Ligature items such as shoelaces, bathrobes, hospital gown ties and belts, and electrical cords or cables.
  • Common facility and space design issues in designated mental health units or rooms:
    • Floor plans with isolated areas;
    • Failure to act on known facility design deficits and equipment issues;
    • Inconsistent use of harm and abuse-resistant materials, furnishings, and fixtures, including ‘breakaway’ (anti-ligature) bars in client rooms (closets), and showers / bathtub;
    • Inadequately located and inconsistently stocked resuscitation carts to respond to self-harm attempts.
  • Common facility and space design issues in EDs and general medical-surgical units:
    • Design and space not conducive to monitoring, observing, and treating at risk clients (e.g., no dedicated or safe rooms for at risk clients);
    • Lack of compliance with security and safety practices for at risk clients.
  • Unauthorized access to unlocked and unattended staff only areas (e.g., linen rooms).
  • Surveillance technology issues:
    • Lack of and / or misuse of audio-video surveillance to augment client monitoring including within seclusion rooms;
    • Inadequate retention and disposal practices.

Mitigation Strategies

Facility and Space Design Decision-Making

  • Implement a best practice mental health environmental hazards checklist to assess inpatient mental health units (Louisiana Hospital Association Trust Funds, 2021) (Watts, Shiner, Young-Xu, & Mills, 2017) (Watts, et al., 2012) (Saskatchewan Ministry of Health, 2012) (OHA Task Force on Suicide Prevention, 2017) (Mills, King, Watts, & Hemphill, 2013) (Perlman, Neufeld, Martin, Goy, & Hirdes, 2011).
  • Ensure facility and space design processes for inpatient mental health and addiction units involves:
    • An interdisciplinary design team or committee involving front line staff, clinical and medical leadership, client advisors, and external consultants;
    • A design decision making framework that is principle and evidence-based (McMurray, 2022).
  • Ensure the design process considers:
    • Therapeutic and healing design elements conducive for cognition and desired positive behaviours;
    • Staff workflow, and efficiency, safety, and security considerations;
    • Risk reduction for elopements, suicide and self-harm attempts, client behavioural incidents as well as client and staff safety and stress.

Additional Considerations

Examples of industry standards / best practice design considerations for designated inpatient mental health units, bedrooms, seclusion, isolation, and restraint rooms:
  • Weight-tested breakaway hardware (e.g., rods, bars and hooks) for blinds, curtains, closets and lockers;
  • Furniture secured to the floor;
  • Windows made of safety glass;
  • Anti-ligature fittings and furniture;
  • Ceiling grilles and grates with small perforations or mesh behind the grill or grate;
  • Solid surface, recessed, or built into the wall ceiling sprinklers, smoke detectors, lighting, and video-audio monitors (where used);
  • Light switches outside of the room;
  • Unbreakable covers and tamper-free screws for fixed and movable items and furniture;
  • Use of paper not plastic garbage bags.

Strategies for Inpatient Mental Health Units

(New York State Office of Mental Health, 2023) (Pankey, et al., 2022) (Canadian Standards Association, 2018) (US Department of Veterans Affairs, 2021)

  • Adopt industry standards / best practice when choosing or updating / replacing doors and related hardware bedroom, bathrooms, and rooms used with at risk clients including rooms used for seclusion, isolation, and restraints.  

Additional Considerations

Examples of considerations when designing or updating / replacing doors in all rooms used with / for at risk clients:
  • Anti-barricade doors systems;
  • Door handle design to prevent the handle from being tied to another anchor point or the bathroom door handle.
  • Doors flush to the floor, with an observation window (keep clients in view) and continuous hinges flush with the wall with rounded tips as well as hinges that open in both directions (where permitted by fire code);
  • Anti-ligature door handles and hardware.
  • Adopt industry standards/best practice for the design of bathrooms accessible by / used by at risk clients. 

Additional Considerations

Examples of considerations when designing or renovating bathrooms accessible by / used by at risk clients:
  • Door designs that balance privacy with safety;
  • Solid surface, recessed, or built-into-the wall shower and bath controls and spigots;
  • Weight-tested breakaway hardware (rods, bars, hooks, etc.).
  • Consider the need for locked entry bathrooms for mixed gender and / or select client population units.
  • Implement industry standards / best practice design considerations and requirements to enhance client observation and safety (e.g., nursing station design to ensure visibility; spaces designed without blind corners or spots; use of convex or doomed mirrors in corners and walkways).
  • Implement strategies to restrict unauthorized client, family, and visitor access to utility, linen, seclusion and secure rooms, and medication rooms as well as housekeeping carts when unattended or not in use.

Environmental Safety Assessments    

  • Implement formal strategies to prevent and respond to door alarm misuse and malfunctioning.

Additional Considerations

Examples of strategies to prevent and respond to door alarm misuse and malfunction:
  • Prohibiting staff from disabling alarms outside of predefined conditions and controls;
  • Conducting scheduled testing of alarms (e.g., daily);
  • Immediately reporting (and documenting) malfunctioning alarms.
  • Implement industry standards / best practice for conducting periodic environmental safety assessments of designated inpatient mental health and addiction care units, general medical-surgical units (admitting / holding / treating at risk clients) as well as EDs.

Additional Considerations

Examples of elements to be included in the periodic environmental safety assessment process:
  • Adopting a standardized evidence-based safety assessment tool;
  • Conducting and documenting point of care testing of risk reduction design features (e.g., weight tested breakaway hardware);
  • Soliciting feedback from staff, clients, and families (e.g., what is working well and should be replicated; what needs improvement);
  • Frequency and method for reporting safety assessment findings, controls, and recommendations to the organization’s quality and / or safety committee.

Strategies for General Medical-Surgical and Emergency Department Environments    

  • Adopt a best practice mental health environmental hazards checklist (OHA Task Force on Suicide Prevention, 2017).
  • In collaboration with internal and / or external mental health and addictions design experts, develop a formal strategy to adopt industry standards / best practice facility and space design considerations (Huddy, 2016).

Additional Considerations

Examples of risk reduction considerations for rooms used for bedrooms, bathrooms, seclusion / isolation, crisis management, and restraint rooms used by general medical-surgical units and EDs when admitting / holding at risk mental health clients:
  • Restricted access to utility and linen rooms as well as lockup of unattended housekeeping carts;
  • Room location and type;
  • Security considerations.

Equipment, Supplies and Technology

  • Implement formal strategies to ensure all mental health and addictions units, treatment and procedures areas (e.g., ECT procedure areas) have dedicated or immediately accessible resuscitation equipment / carts to respond to self-harm attempts as well as cardiopulmonary arrests (Royal College of Psychiatrists, 2022) (Tang & Fadlalla, 2022).
  • Implement formal strategies to ensure designated safe, crisis, and restraint rooms, as well as surveillance technology, are not used as a replacement for in-person and face-to-face client observation where indicated (Huddy, 2016) (Pankey, et al., 2022).

Monitoring and Measurement

  • Adopt a standardized, interdisciplinary, collaborative, and evidence-based protocol for conducting quality of care reviews involving client elopements and suicide attempts resulting harm or death to self or third parties (Incident Analysis Collaborating Parties, 2012) (Machen, 2023); incorporate system thinking and human factors concepts into the review process. 
  • Ensure facility and space design is incorporated into quality indicators for mental health and addiction services.
  • Incorporate learning from local, provincial, and national elopements, death by suicide / attempts while in care and harm to third party safety reviews and data involving at risk clients into local protocols as well as staff, client , and family education and training. 

  • Agency for Healthcare Research and Quality. (2023). Preventing falls in hospitals. Retrieved from
  • Canadian Standards Association. (2018). Z8000-18 Canadian health care facilities. 
  • Health Quality Ontario. (n.d.). System performance. Retrieved from Indicator Library:
  • Huddy, J. (2016). Design considerations for a safer emergency department. Dallas, Texas: American College of Emergency Physicians.
  • Incident Analysis Collaborating Parties. (2012). Canadian Incident Analysis Framework. Edmonton, AB.
  • Louisiana Hospital Association Trust Funds. (2021). Behavioral health safety checklist. Baton Rouge, LA.
  • Machen, S. (2023, 5). Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Quality, 12(2), e002020.
  • McMurray, K. (2022). Behavioral health design guide. Behavioral Health Facility Consulting, LLC .
  • Mills, P., King, L., Watts, B., & Hemphill, R. (2013, 9). Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards. 
  • New York State Office of Mental Health. (2023). Patient safety standards, materials and system guidelines. 
  • OHA Task Force on Suicide Prevention. (2017). Strengthening suicide prevention in ontario hospitals. Ontario Hospital Association.
  • Pankey, V., Barderll, P., Browne, E., Cartrette, A., Giebink, B., Masters II, R., . . . Zeller, S. (2022). Design of behavioral health crisis units. Facility Guidelines Institute.
  • Perlman, C., Neufeld, E., Martin, L., Goy, M., & Hirdes, J. (2011). Suicide risk assessment inventory: A resource guide for canadian health care organizations. Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute.
  • Royal College of Psychiatrists. (2022). Electroconvulsive therapy (ECT). 
  • Saskatchewan Ministry of Health. (2012). Appendix C. Checklists & access to means auditing, outcome measures and quality assurance for Saskatchewan health care providers. In Saskatchewan Suicide Framework. 
  • Tang, S., & Fadlalla, I. (2022, 6). Availability and Functionality of Physical Health and Resuscitation Equipment in an Inpatient Setting: A Closed Loop Audit Cycle. 
  • US Department of Veterans Affairs. (2021). Safe patient handling and mobility design criteria. 
  • Watts, B., Shiner, B., Young-Xu, Y., & Mills, P. (2017, 4). Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. 
  • Watts, B., Young-Xu, Y., Mills, P., DeRosier, J., Kemp, J., Shiner, B., & Duncan, W. (2012, 6). Examination of the Effectiveness of the Mental Health Environment of Care Checklist in Reducing Suicide on Inpatient Mental Health Units.