Designing Spaces for Behavioral and Mental Health Treatment

From the ground up, a balance of care and safety is why the floor matters
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Sponsored by Tarkett
By Sandra Soraci, EDAC, LEED AP, NCIDQ, and Kathy Price-Robinson
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Safety Risk Assessment Tool

The CHD developed the Safety Risk Assessment (SRA). The Facilities Guideline Institute (FGI) Guidelines Section 1.2-4 requires a Safety Risk Assessment (SRA)7 to determine the level of risk acceptable for both patients and staff in each part of the patient-accessible areas of behavioral health units. The SRA Report is vital and must be consulted in reaching all safety-related design decisions.

What is the SRA?

The Safety Risk Assessment (SRA) Toolkit is:

  • A proactive process that can mitigate risk
  • A discussion prompt for a multidisciplinary team
  • An evidence-based design (EBD) approach to identify solutions.

The SRA targets six areas of safety (infections, falls, medication errors, security, injuries of behavioral health, and patient handling) as required in the FGI Guidelines.

A Systematic Approach for Creating a Safety Risk Assessment8

From this collaborative effort, informed selection, specification, and procurement for BMH centers, including the flooring, will be gleaned.

Behavioral Health Design Guide

The Behavioral Health Design Guide9 is updated frequently to keep pace with new knowledge about patient safety and new products for use in behavioral health facilities.

The Guide addresses patient safety in the built environment for the adult inpatient mental and behavioral healthcare units according to how the space is used by patients and rates those spaces I through V (see next page). Level I areas are those that patients cannot access and, therefore, pose the least concern. Level V areas are those where patients and staff interact and where patient behavior is unpredictable, thus posing the most significant concern. The Guide’s authors describe each area’s obvious and latent hazards and offer insights into reducing risks with thoughtful design and appropriate furniture and fixtures.

VA Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities

This Veterans Administration Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities sets the standards for treating veterans. It is also a useful guide for non-veteran facilities. As with other guides, this one seeks to balance a welcoming, nurturing environment with a safe setting for patients, staff, caregivers, and visitors.

Secure installation specific to the floor and wall base prevents flooring from being torn or removed by inpatients to cause harm to themselves or others. Floors with high glare may adversely impact visual perception for psychotic and older patients and, therefore, should be avoided. Suitable flooring considerations include resilient sheet, linoleum, and sheet vinyl flooring. Seclusion Rooms require flooring with an integral base and floor-to-ceiling and wall-to-wall resilient wall protection or rigid wall panels.

To achieve a more homelike environment, resilient sheet, rubber, linoleum, and sheet vinyl flooring with wood grain appearance may be used in some areas or throughout the unit. Accent or other patterns are also available and may help with wayfinding. A flooring that does not require floor finish is highly recommended.

Due to its homelike feel, sound absorption, and ease of replacement, carpet tile is recommended as a flooring option in certain areas. Carpet tile should have an upgraded moisture guard or moisture-resistant backing system. Carpet tile should be used only in supervised patient areas such as group therapy, day rooms, dining rooms, intake/interview rooms, recreation/activity areas, and staff areas such as conference rooms and office areas. Hybrid resilient sheet flooring solutions provide the look, feel, and noise control and moisture qualities of carpet while also creating a surface to address infection control, cleaning, and ease of maintenance.

Facilities Guidelines Institute (FGI)

The Guidelines for Design and Construction documents are updated every four years to keep pace with evolving care delivery models, facility types, and requests for up-to-date guidance from care providers, designers, and regulators.

For the 2022 edition, the Facility Guidelines Institute (FGI) has published three Guidelines for Design and Construction standards with distinct planning and design requirements for hospitals (including behavioral and mental health), outpatient facilities and residential health facilities, residential care and support facilities, and nonresidential support facilities.

The Guideline’s standards are important in planning, design, and construction because federal agencies, states, and local jurisdictions adopt them as law and apply them as a standard against which to evaluate building projects. Though they are guidelines and not building codes at a federal or state level, they hold tremendous weight in the design and decision-making process as a path to compliance and minimum requirements.

FGI Guidelines Impact Flooring Selection, Specification, and Procurement

Flooring can have an actionable impact on operational optimization and clinical efficiency, reduce associated person-hours to maintain, and reduce the total cost of ownership. These product attributes result in optimized processes and effective life cycle costs over time—all sustainably. Flooring can positively impact patient experience, mitigate cross-contamination, foster safety, and reduce caregiver fatigue. Flooring should be viewed as a system, from the subfloor to the surface finish. In support of specifying the right product for the right space, the FGI Guidelines are a source to ensure the right flooring product is specified in support of health, wellness, and safety.

Flooring specification in the BMH setting; safety is paramount to prevent patients from potentially harming themselves or their caregivers. Flooring installation detail in high-risk areas must mitigate weaponization and self-harm.

FGI, Behavioral Health Design Guide, and the New York State Design Guide speak to these four categories for flooring details:

  • No flooring cap
  • Tamper-resistant
  • Impact-resistant
  • Water-resistant/cleanable

The proper design of facilities for BMH patients is both highly consequential and complex. If not specialized in the BMH setting, architects and designers often collaborate with highly experienced consultants in the specialized field.


In an issue brief, CHD notes that most design teams acknowledge that providing BMH patients with a healing, therapeutic environment should be an important goal for health design. However, the evidence base for designing for BMH in medically oriented healthcare facilities has focused almost exclusively on physical safety. While safety is obviously the right place for the healthcare design community to start when designing for BMH, it is clearly not the right place to stop.

Finishes and furnishings in behavioral and mental health centers can be subjected to abuse. Materiality matters to withstand daily demands and heavy use. Carefully consider the selection, specification, and procurement of interior finishes, including the flooring, as it can impact the cognitive, emotional, psychosocial, and physical needs of patients, residents, staff, and caregivers.

In selecting and specifying interior finishes, specialty manufacturers focus on safety features while mitigating an institutional look and feel. Supporting the needs of safety and healing enables the transition of care from inpatient to outpatient or residential care with a homelike setting.

The Intersection of Aging, Behavioral, and Mental Health

In a brief on the connection between aging and mental health,11 the Center for Health Design notes that by 2031, the largest segment of the U.S. population—the Baby Boom generation—will reach the age of 85. At this age, the brief notes, people experience the most significant and extreme effects of the normal changes associated with aging. It is also the age associated with the highest risk of developing dementia, particularly Alzheimer’s disease.

Many design features that serve BMH patients also serve those in memory enhancement facilities, including a homelike setting and access to nature and natural environments. Further benefits include simplifying the layout of the spaces, reducing the scale, enabling interactions between those with and without dementia, and personalizing bedrooms.

As the need increases for both BMH and dementia care, research and experience concerning therapeutic and safe design can serve both interests.

Photo courtesy of Tarkett

The flooring pattern can evoke scenes from nature and calm patients with soft, soothing colors.

Human Connection to the Natural World

Metropolis magazine shared that if the design doesn’t focus on aspects of the natural world that contribute to human health and productivity in the age-old struggle to be fit and survive, it’s not biophilic. Simply put, biophilic design focuses on those aspects of the natural world that have contributed to human health and productivity. Another distinguishing feature of biophilic design is its emphasis on the overall setting or habitat and not a single or isolated occurrence of nature.

The magazine shares that biophilic design depends on repeated and sustained engagement with nature. An occasional, transient, or isolated experience of nature exerts only superficial and fleeting effects on people and can sometimes be at variance with fostering beneficial outcomes. Biophilic design requires reinforcing and integrating design interventions that connect with the overall setting or space.


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Originally published in November 2023