Proposed behavioral health crisis unit requirements support development of facilities where behavioral health patients who come to a hospital in a state of crisis can be cared for in a calm environment such as this multiple-patient observation area in a University of Iowa Health Care crisis stabilization unit.

Photo by Main Street Studio

The Facility Guidelines Institute (FGI) is inviting users of the FGI Guidelines to comment on revisions and additions featured in its draft 2022 documents. 

Input from Guidelines users is a crucial step in revising the Guidelines documents, which provide minimum standards for design and construction of hospitals; outpatient facilities; and residential health, care and support facilities, and are used by many states to regulate design and construction of these facilities.

The Health Guidelines Revision Committee (HGRC), the multidisciplinary body responsible for development of the content of the Guidelines, works to update the documents every four years. The goal is to keep the documents up to date with changes in the health care field and to provide clarifications that can ease adoption and compliance.

Users of the Guidelines are asked to provide feedback on revisions to the 2018 FGI Guidelines for Design and Construction of Hospitals, Guidelines for Design and Construction of Outpatient Facilities and Guidelines for Design and Construction of Residential Health, Care, and Support Facilities

The drafts will be posted for public review from July 1 to Sept. 30, 2020. Major changes proposed for all three 2022 FGI Guidelines documents are outlined in this article.

Overall revisions

The draft 2022 Guidelines for Design and Construction includes several updates to Guidelines-wide terminology. “Patients of size” was changed to “individuals of size” to more accurately and consistently describe those who may be patients, visitors, family members, participants, residents and staff. 

Previous references to “psychiatric” facilities, patients and assessments have been updated to “behavioral and mental health” in response to recommendations from the HGRC and two FGI behavioral health topic groups with representation from organizations operating in the medical/behavioral health sector.

Changes proposed for the Hospital and Residential Guidelines documents recognize that the design of settings where palliative care is delivered directly affects the patients and residents receiving treatment and end-of-life care. Minimum requirements and recommended considerations for palliative care design are offered for the planning phase of a project.

FGI’s “Inclusive Environments Topic Group” introduced changes to provide better support for all populations in health care and residential care facilities. Incorporated in the Hospital draft are requirements and recommendations for use of color and light to accentuate contrast between surfaces and for selection of flooring patterns to support those with low or declining vision, balance, mobility or other physical abilities. 

A section titled “Design Criteria for Inclusive Environments” has been added to the Outpatient draft to provide a basic requirement to consider the needs of the patient population and changing staff demographics during project planning and design. Recommended criteria are included in the appendix to encourage a universal design approach to create supportive environments for patients, visitors and staff.

Recommendations for a noise risk assessment have been added to the appendix in the Hospital and Outpatient drafts in recognition that noise-induced hearing loss is a public health concern. The proposed text suggests evaluating the impact of noise on speech privacy, speech intelligibility and occupant health. This addition was inspired in part by a 2017 Centers for Disease Control and Prevention report that identifies the dangers of exposure to high levels of environmental noise.

Several new clinical spaces appear in both the Hospital and Outpatient drafts. To address issues seen in many emergency facilities, design requirements for a low-acuity patient treatment station and a behavioral health crisis unit have been included. The former is a 40-square-foot space intended to improve patient flow, reduce average length of stay, increase space utilization and improve cost efficiencies. The latter is a unit that makes it possible to divert behavioral and mental health patients from the emergency department (ED) and supports a deinstitutionalized approach to care for this population. 

To help address crowded conditions in many EDs, requirements have been proposed for spaces to accommodate low-acuity patients who do not require extensive clinical services and do not need a bed, such as these low-acuity patient treatment stations at the Medical University of South Carolina.

Photo by John D. Smoak, III

Another new space is a unit for an intensive outpatient and partial hospitalization program (IOP/PHP). These treatment programs support patients with behavioral and mental health diagnoses who do not require inpatient care, but may be used in conjunction with inpatient programs to help clients adapt more comfortably.

Among the updates to the Hospital and Outpatient documents are clarified requirements for clean and sterile supply storage in an operating room suite and a refinement of the imaging requirements that were significantly reworked for the 2018 edition.

For all three documents, mechanical and electrical systems are now required to follow ANSI/ASHRAE/IES 90.1, Energy Standard for Buildings Except Low-Rise Residential Buildings, in the absence of a local- or state-adopted energy code.

Hospital Guidelines

In Chapter 1.2, Planning, Design, Construction, and Commissioning, recommendations are provided in the appendix section on the behavioral and mental health risk assessment, which is used to consider risk levels relative to the type of space, patient acuity and whether the patient is alone or among other patients and staff. A fourth risk level was added to the assessment to better align with leading industry practices.

Based on recommendations from infection preventionists, the determination of whether an anteroom is required for an airborne infection isolation (AII) room will now be based on an infection control risk assessment (ICRA). The ICRA will determine the need, quantity and placement of anterooms. A new appendix outlines considerations for determining when an anteroom is required, including infection prevention concerns and its use for storage, donning and doffing, and disposal of personal protective equipment.

Several specialized care units have been proposed for the 2022 Hospital Guidelines. Minimum requirements and recommended best practices have been introduced for burn units and hospice units.

Guidance on ED design was adapted to increase the flexibility of room use, along with the accessibility and safety of public waiting areas and toilet rooms. Design requirements for human decontamination areas have been expanded to include outdoor areas. 

Language encouraging use of the critical access hospital chapter for design of small and specialty hospitals, where appropriate, has been added. Revisions of guidance for small, rural and critical access hospitals focus on requirements that allow increased flexibility of room use.

The Guidelines chapter on freestanding emergency care facilities has been removed from the Hospital Guidelines and will be included in the Outpatient Guidelines only, as Chapter 2.8. Guidelines users should look at the Outpatient draft to comment on changes to this material.

Outpatient Guidelines

Several revisions in the Outpatient draft apply to multiple outpatient facility types. These include removal of the clear floor area requirement for various patient care stations, allowing clearances to determine their size as was done for other spaces in the 2018 Guidelines; clarification of requirements for pharmacies and other medication preparation facilities; and additions and clarifications to the requirements for staff support areas and architectural details in chapters lacking this information.

Chapter 2.2, Specific Requirements for General and Specialty Medical Services Facilities, features a new appendix table with examples of how the chapter could be applied to specialty care facility types.

A notable change in Chapter 2.4, Specific Requirements for Birth Centers, is the reduction of the minimum size for a birthing room from 200 square feet to 120 square feet. This change was influenced by a national study of U.S. birth centers, which found that 25% of existing birth center rooms were less than 200 square feet. As well, food service requirements have been made optional, because many birth centers do not provide food service.

In Chapter 2.5, Specific Requirements for Urgent Care Centers, the section on patient care areas has been reorganized for clarity and to add flexibility for the design of triage areas, exam rooms and treatment rooms. In particular, requirements for a multiple-patient exam room were added. Chapter 2.10, Specific Requirements for Renal Dialysis Centers, contains new text supporting Centers for Medicare & Medicaid Services requirements for fluid disposal sinks in the hemodialysis treatment area and a dedicated room for patients with special precaution needs such as Hepatitis B. The AII room was removed, as patients needing an AII room do not generally receive dialysis in an outpatient setting.

Chapter 2.11, now titled Specific Requirements for Behavioral and Mental Health Centers, features requirements for two new optional spaces: IOP/PHP facilities, as mentioned previously; and transcranial magnetic stimulation (TMS) rooms. TMS therapy, a noninvasive form of brain stimulation, is useful for patients experiencing depression, post-traumatic stress and other disorders.

A new chapter has been proposed for extended stay centers that are associated with outpatient surgery or freestanding emergency facilities. 

These centers support patients who are stable and do not need intensive monitoring or hospital-level care but — because of distance, travel limitations, lack of a caregiver at home, or more time needed to manage pain or bodily functions — may not be able to go home the same day as a procedure or visit to an emergency facility. A few states already regulate these facility types, and design guidance is needed.

Residential Guidelines

Part 1, General, and Part 2, Common Elements for Residential Health, Care, and Support Facilities, in the draft 2022 Residential Guidelines feature additions and revisions on numerous topics, including lighting, telemedicine, handrail construction, kitchen design and interior noise requirements. 

Planning requirements and recommendations for lighting and daylighting have been expanded to provide guidance for accommodating visually impaired residents/participants, visitors and staff. Lighting recommendations to support healthy circadian rhythms are also included. 

Handrail and lean rail requirements have been revised to better distinguish when and where each rail type is needed.

Telemedicine guidance is now consistent with the requirements in FGI’s Hospital and Outpatient documents. The sections on technology equipment and teledata rooms have been overhauled and appear under the heading “Telecommunications Systems.” This section features revisions for the technology equipment room and new requirements for a technology distribution room.

Kitchen types have been revised and the requirements consolidated and relocated to one section on food service facilities. Kitchen types included are commercial, retail, household, social activity, outpatient therapy and warming/serving kitchens. 

Table 2.5-2, Maximum Design Criteria for Noise in Interior Spaces Caused by Building Systems, lowers the acceptable decibel level in resident rooms and increases the acceptable decibel level in dining rooms. The table adds new sound level requirements for telemedicine rooms and teleconferencing areas.

Parts 3, 4 and 5 of the Residential Guidelines contain requirements for common facility types in residential settings. Revisions and additions to these chapters include space requirements for resident rooms and nursing home spaces. 

Space requirements for resident rooms in Chapter 3.1, Specific Requirements for Nursing Homes, have been revised significantly, requiring new facilities to meet a minimum clear floor area of 120 square feet in single-resident rooms and 108 square feet per resident in multiple-resident rooms. An exception is provided for resident rooms in renovated nursing home facilities. 

The nursing home chapter also includes provisions for single-resident rooms for individuals of size, with a minimum clear floor area of 200 square feet when an overhead lift is provided and 219 square feet when mobile lifts are used.

An option for dialysis facilities in nursing homes has been added in recognition that training for home care dialysis is often provided there. 

Chapter 3.2, Specific Requirements for Hospice Facilities, has been significantly revised and now requires hospice rooms to have a minimum clear floor area of 153 square feet, which includes a family support zone of 33 square feet.

Finally, assisted living care model typologies and characteristics have been rewritten and streamlined. The three typologies described are residential, household and apartment-style community models.

Get involved

FGI urges all those involved in planning, design and construction of health care and residential health, care and support facilities to contribute to the development of the 2022 Guidelines standards by participating in the comment period. 

Public input during the revision process is vital to keep the FGI Guidelines current with practices in the field.

This article was written by the staff of the Facility Guidelines Institute.

About this article 

This feature is one of a series of articles published by Health Facilities Management in partnership with the Facility Guidelines Institute.