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Numerous trends indicate growing demand for behavioral health services. For example, a study in The American Journal of Emergency Medicine (December 2020) indicated adult emergency department (ED) visits increased by 8.6% from 2006 to 2011, but ED visits for mental health disorders increased by 20.5%. And while the national number of pediatric ED visits remained stable over the last decade, according to a study published in Pediatrics (May 2020), pediatric ED visits for mental health disorders rose 60%. Furthermore, ED visits resulting in admissions or transfers to another facility are over 50% higher for mental health-related visits than other visits.

Increased Demand for Contemporary Behavioral Health Facilities

The increased demand for behavioral health services is creating even more demand for behavioral health facilities. According to the American Society for Health Care Engineering, 40% of the specialty hospitals under construction in 2020 were psychiatric hospitals and behavioral health centers, far more than other types of specialty hospitals in recent years.

While owners are trying to keep pace with patient demand for services, they are also updating and replacing outdated spaces to better reflect current clinical best practices for their patients. Contemporary research into the impact of one’s environment on their health has inspired a new generation of facilities that feel more welcoming and residential, safely offer more privacy, and increase the use of design elements that contribute to well-being.

For example, evidence-based design recommends more exposure to nature – through features like greenery, windows with views and outdoor spaces – to reduce cortisol levels and stress for patients and their caregivers. Similarly, increased access to natural light and space for recreation and exercise, plus reduced noise can also contribute to improvements in mood and enhance treatment progress. Likewise, sensory features and rooms are becoming more common, thanks to their enhancement of self-care, crisis de-escalation, relaxation, and feelings of personal control and safety.

Increased Potential for Behavioral Facility Project Pitfalls

The convergence of these trends has the potential to create countless pitfalls for behavioral health facility projects. For instance, because demand is so strong, lead times are longer for many specialized products and could easily threaten project schedules. Also, as research and best practices continue to evolve and shape behavioral health designs, the fewer seasoned experts and more novices likely to be involved – from design firms to construction firms and trade partners, to state and local authorities responsible for inspections and code enforcement. Finally, the behavioral health industry is challenged by high staff turnover rates. Frequent changes to project team members and key end users can impact the team’s continuity and alignment, and therefore decision-making and schedule, throughout a project.

In this dynamic environment, project teams can rely on several best practices to prevent these circumstances from derailing behavioral health projects.

Proactively Invest More Time & Communication

Since behavioral facility project teams are often charting new territory and at least a few firsts, proactively allowing more time for critical decision-making, reviews, approvals and communication is key. “For behavioral health projects, allocating enough time to ensure shared understanding about what everyone wants, make decisions, ordering specialty products, and conduct inspections is a smart strategy,” said Jeff Wherry, a healthcare senior project manager at JE Dunn. “Giving additional attention to client coordination early in the process and ample time to educate everyone about the unique aspects of these facilities prevents issues and delays.”

Extra time is often needed for coordinating even the smallest details. “Coordination for items like caulk, doors and hardware might require one or two meetings on a typical healthcare project,” said Josh Meadows, a JE Dunn healthcare vice president. “But on a behavioral project, you might need several more meetings to involve all the right people and allow ample time for exploring options and getting everyone comfortable with the final decisions since the requirements are often unique or new to the client.”

In fact, Meadows recommends project managers develop a roadmap at the beginning of the project, outlining all the people needed at various stages for each decision along the way. This provides a starting point for monitoring any changes to project, partner, and owner staffing, as well as changes to any client or regulatory guidelines, and then adjusting to remain nimble despite changes.

Leverage Experience & Education

Given the shortage of contemporary behavioral health design and construction experience, owners should involve partners with experience when possible, so they can help educate others newer to this specialty. “Working with architectural designers and MEP (mechanical, electrical and plumbing) engineers with behavioral health experience is a game-changer,” said Mike Trehey, a healthcare senior project manager with JE Dunn. “I encourage owners to select partners with a diverse resume of behavioral health experience – renovations and greenfield projects, emergency and inpatient settings, and facilities for adults and pediatrics. It will improve project outcomes and ease decision-making every step of the way.”

Partnering with experienced firms not only provides valuable insight and wisdom, but it also allows for proactive education of less experienced stakeholders. “Having project leadership with behavioral health experience benefits everyone, since they can help educate team members who aren’t as familiar with these facilities. That way no one has to learn through a ‘school of hard knocks’ approach,” said Preston Pressley, BakerTriangle’s vice president of business development and marketing. Due to the unique nature of some aspects of these facilities, like access control, which is even more secure than a typical healthcare facility, project teams may have to educate and guide countless stakeholders throughout the project. “Being able to educate others can make the difference between obtaining responses and approvals in days versus weeks,” shared Bill Igel, a JE Dunn healthcare vice president.

Leading with a “Safety First” Mentality

Safety is a significant priority in any healthcare setting. But when patients are more likely to try harming themselves or others, every detail of a facility must be further scrutinized to ensure everyone’s safety.

One nuance a newcomer may find challenging is the diversity of risk tolerances and safety approaches from one facility to the next. This variation stems from several sources. First, the risk posed by patients depends on the acuity level and patient demographics for any given facility. Secondly, different staffing models and designs may warrant varying degrees of safety engineered into the built environment. “Clients with greater staff-to-patient ratios or more visibility and better sightlines to patients throughout the facility may tend toward slightly less robust anti-tamper or access control features than another facility with different circumstances,” said Igel, “while still maintaining a safe environment.”

One key to an effective “safety first” mentality is to try viewing and experiencing the environment through the eyes of patients who might want to harm themselves or others. Project teams can achieve this in several ways. “Conducting mock patient walk-throughs with the facility’s staff can help the entire project team see and experience the facility more like a patient,” advised Wherry. And depending on the circumstances, teams can even coordinate with the facility to conduct security and safety walk-throughs with patients.

These patient safety and security reviews should begin during the design process to anticipate any issues before construction begins. After the groundbreaking, similar reviews should happen at regular intervals throughout the entire project. “The more people involved with reviewing the facility for patient safety and security, the better,” shared Igel. “Encouraging the owner, design partner, construction management and trade partners to try experiencing the facility more like a patient helps build more awareness, understanding and empathy, so everyone can be more proactive about creating the absolute safest facility for patients and staff.”

Project teams should also consider contracting with a third-party ligature consultant to review the drawings and walk the jobsite at various points throughout the project. This additional layer of review can provide more reassurance and peace of mind, enhance patient and staff safety, and help prevent expensive rework and delays.

Specialized Construction Practices for Specialty Facilities

Behavioral facilities’ unique requirements warrant a similarly unique approach to several aspects of construction management. For example, involving as many trade partners as possible with behavioral experience will help set up the project for success. As Meadows suggested, “Try to find someone who has the industry contacts to make the right decisions and quickly adjust plans as needed along the way.”

Secondly, Meadows recommends subcontracting differently. “Hire one trade partner to provide pick proof caulk for the entire project. And make sure security is also contracted separately – not through an electrical or hardware partner. That way one partner is responsible for all security and access.”

In a behavioral facility, even the littlest details can pose security risks, and standards are always evolving, so leaders must stay current with best practices. “As an example, snake eye screws used to be standard for behavioral projects,” said Wherry. “But the current best practice is a pin torque screw. Everyone uses screws, including the furniture manufacturers. So, if the team does not identify the correct screw for use on the entire project in the beginning, it can quickly create countless issues.”

Project teams and owners embarking on their first behavioral project should also be advised about the impact of security and safety on accessibility, and therefore, project schedule. For instance, any space that is not constantly monitored by staff will typically require a hard lid ceiling.

“Behavioral projects could have as much as 40% less access to the buildings’ above-ceiling systems than typical healthcare facilities,” advised Trehey. “Therefore, everything above the ceiling must be completed, or securely accessible, before working on other aspects of the project.” Without experienced project leadership, this could easily threaten the project schedule.

Finally, due to potentially long lead times for certain fixtures (like shatter-resistant light fixtures and ligature-resistant doors, bathroom fixtures, doorknob, and diffusers), selecting and ordering these products early in the project is critical to maintaining schedule certainty. “In this high-demand environment, I recommend double-checking suppliers’ lead times for specialty items and consider allocating additional time to protect your schedule,” cautioned Meadows.

Leveraging Tried & True Construction Management Practices

While behavioral projects do warrant unique practices and approaches, project teams should also leverage construction management best practices to ensure the project’s success. Early involvement of contractors and key trade partners during design, embracing lean principles, and extensive use of VDC and BIM will positively impact budget, schedule, and quality, while also fostering the additional communication and collaboration necessary for behavioral projects.

Furthermore, “optimizing plans around prefabrication can also positively impact a behavioral project’s schedule and mitigate for the longer durations involved with decision-making and purchasing,” said Wherry. The early involvement of all stakeholders and heavy reliance on BIM before construction are perfect complements to prefabrication. “With benefits like greater cost certainty and quality control, and less disruption to ongoing campus operations, projects with a comprehensive approach to optimizing prefabrication can enhance our speed to market by more than ten percent – potentially several months – which allows us to provide these valuable services to patients even sooner,” said Todd Curry, senior manager of design and construction at HCA Healthcare.

And while user groups with key staff and caregivers are important for most healthcare projects, they are equally, if not more important for behavioral projects. “Not only is there a national shortage of behavioral health workers,” said Igel, “but the industry is also impacted by high rates of burnout and turnover.” So, early input and buy-in from the staff who will care for patients long after construction is of utmost importance. “We want to do everything we can to ensure the facility helps staff feel safe and secure, and also contributes to their health and well-being at work,” shared Meadows. “We want to deliver a facility that allows them to be at their best for their patients.”

A Comprehensive Plan for Success

Each behavioral project, its patients, and staff are unique and require a customized, informed approach to delivering a high-quality environment for healing. While demand for behavioral health care, and therefore facilities, is likely to continue growing, and the best practices for design and construction are likely to continue evolving, certain strategies can ensure success for each project. Involving experienced partners and focusing on a patient-centric, collaborative approach, combined with a safety-first strategy, and tried and true construction management practices are keys to optimizing project outcomes.

Above all, successful project teams must start and end each project with a solid foundation of proactive communication planning, a commitment to continuous learning and listening, and empathy for the facility’s staff and the patients they serve.