Citation
R.M.C. & Mount Airy Psychiatric Center

Material Information

Title:
R.M.C. & Mount Airy Psychiatric Center
Creator:
Johnson, Geoffry R
Publication Date:
Language:
English
Physical Description:
113 leaves : illustrations, charts, facsimiles, plans ; 28 cm

Subjects

Subjects / Keywords:
Psychiatric hospitals -- Design and construction ( lcsh )
Psychiatric hospitals -- Design and construction ( fast )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 110-111).
General Note:
Cover title.
General Note:
Submitted in partial fulfillment of the requirements for a Master's degree in Interior Design, College of Design and Planning.
Statement of Responsibility:
Geoffry R. Johnson.

Record Information

Source Institution:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
09898227 ( OCLC )
ocm09898227
Classification:
LD1190.A75 1983 .J5374 ( lcc )

Full Text
environmental design auraria library
R.M.C. & MOUNT AIRY PSYCHIATRIC CENTER
ARCHIVES
LD
1190
A75
1983
J5374


This Designer would like to thank his advisors, John E. Ellis (Project Manager-Interiors-W.C. Muchow & Partners, Inc.), T. Scott Meiners (Associate Administrator-Mount Airy Psy. Center), and Chris Nims (Interim Director of Interiors UCD), for their assistance during the research and design development of this project. Special appreciation is extended to MOUNT AIRY PSYCHIATRIC CENTER for allowing me to use their proposed development as a thesis project. Additional thanks are extended to those institutions who welcomed my presence when evaluating their facilities and to those individuals who were willing to respond to personal interviews.
GEOFFRY R. JOHNSON DENVER, COLORADO MAY, 1983


PREFACE
The following Master Program is intended to be the basis for the design and implementation of the interiors of the "R.M.C. & Mount Airy-Psychiatric Hospital". My Master's Thesis design presentation will deal with the building envelope, space planning and overall design development of the facility in areas to be identified later.
"All that man knows is derived thru the means in which he perceives life. To Touch, to Smell, to See and Feel provides man with a pathway thru life. The knowledge that he extracts from his environmental experiences will greatly determine his ability to cope with the environment." (Johnson 83')
2


Table of Contents
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ft
BACKGROUND Page
Social Attitudes 5
History of Environment 7
Psychiatric Services Facilities Defined 11
Current State of the Industry 15
Graphic Examples 18
Evolution of Project 42
Justification for Facility & Project 43
Facilities Present Position 44
PROBLEM STATEMENT
Description of Project 44
Scope of Project 45
Design Objectives
Children's and Adolescent Unit Objectives 45
Therapeutic Services Center Objectives 45
Occupational Therapy 47
Education Department 47
Therapeutic Recreation 48
Design Issues
Human/Psychological 48
Physical 50
Economic 58
Time 62
FACTS
Human Factors-User Profiles
Clients (Patients) 63
Staff 64
3


FACTS Con't
Page
Molecular Activities
Scenario of Admissions 72
Scenario of Day's Acitivities 73
Unit and Facility Activities Defined 74
Unit Staffing Chart 77
Specific Facts
Related to Children's and Adolescent Units, "Therapeutic
Services Center" and Administrative Functions 78
Facts that relate to Problems with Present Facilities 81
Facts related to Lighting 84
Facts related to Play and Education 87
Space List 89
CONCEPTS
Written Concepts 96
Matrix of Program Interrelationships 101
Conceptual Organization of Gross Space 102
Functional Diagrams 103
PROBLEM STATEMENTS 106
BIBLIOGRAPHY 110
ON SITE VISITS 112
APPENDIX (Under Separate Cover)


BACKGROUND
Social Attitudes
Through out history mental illness and its* treatment has for the most part been kept in the shadows "out of sight, out of mind" as many in society still would wish it to be. The effects of such conditions have conjured up terrifying visions; raving lunatics out of control with others chained in cells or bound in straight jackets. Although this was true in the dark ages of psychiatry; situations and treatment modalities have changed considerably; yet the image instilled in man is still that of the past.
A large portion of society still fears the thought of themselves, a friend, or a relative having to go to such a place. Even worse, they might have a treatment facility within close proximity of their personal dwelling. In addition, people still fear that if one has to make use of or be sent to a mental hospital they are forever branded a "mental case: for the rest of their lives, unable to get the jobs they wish or other rights guaranteed by the Constitution. Unfortunately, their fears are somewhat justified as many employers still discriminate against anyone who has availed themselves of such serviceso
Even though treatment modalities have changed considerably, many facilities sitll persist in maintaining a physical attitude of "hospital" (slick), institutional in appearance inside and out. This is certainly not conducive to a good accepting public image "that mental illness is ok, treatable and not the horrors as espressed by the past". Psychiatric
Exorcising a demon 16lh ceniury woodcul
5


Bedlam a Hogarth drawing of a scene tn the notorious Engli^ln
hospitals (interiors) of the "ward" are still vaguely reminescent of the past and perpetuates that negative environment to the public sector and most important to the primary patient in treatment. Even the entertainment media continues to dramatically conjure up the image of locked wards with raging, murderous lunatics because of its' profitable shock value; a price which the public and patients pay dearly for in the end. Society's negative attitudes continue to keep ten billion a year in revenue locked up which is the estimated loss in the work force because of increased mental illness and lack of proper treatment facilities.
Communities contnue to fight against any rezoning attempts that may be made when new facilities are in need, citing the fears of the past. It's essential that these fears attributed to such centers be diminished and disolved so that needed treatment not to be tainted or interfered with by society's social fears and impositions. It is felt that such changes can be achieved through humanistic architectural design and like treatment programs that focus on a normal healthy like environment, rather than emphasizing pathology. It tends to place life experiences to the side and are often neglected.
6


History of Environemnt
Historically, development in the area of child and adolescent psychiatry was not seen until the 1930's and 40's and only then on a limited basis in 1) general hospital settings; 2) private schools where parents shuffled off their kids who were two troublesome; 3) troubled kids placed in orphanages by state governments. Before that time they were subject to some of the same conditions as adults. Gradually those involved in adult psychiatry began to notice a dramatic increase in child and adolescent admissions to general psychiatric wards. Such admissions demanded that new programs and modalities be developed for this increasing problem. Yet children and adolescents were still being grouped with adults. It wasn't until the middle late 60's and early seventies that space specifically for the treatment of these age groups was set aside.
As we will see in the following historical background of the proposing facility, Mt. Airy Psychiatric Center (MAPC) was early to recognize the needs in the community for units devoted to there specific age groups, although bureaucratic barriers have hindered their dreams of a unit soley designed for children. They have sometimes been first on their inovative implementation of various programs including some on the adolescent unit. It is expected that this will continue in the new facility and its' new childrens' unit.
The history and growth of Mt. Airy is important in understanding the motivation and goals to be achieved in their new proposed facility.
Mt. Airy since 1903 has pioneered advances in psychiatry and has helped move public thought about mental illness from demonology to a better understanding such as one might have towards other ailments such as pneumonia or cancer. Innovation has been a hallmark of Mt. Airy during its' near eighty year history as the oldest and largest private mental hospital between the midwest and the Pacific coast. Its' very conception in 1903 was an innovation, a then-unique alternative to stashing a mental patient behind the bars of a jail or state institution. Modern psychiatry at that time was in it's infancy.


The Mt0 Airy Sanitarium began when a Dr. Elwin J. Courtney purchased adjoining houses at 1201 and 1205 Vermont (now Clermont) Street and a third at 1180 Vermont Street. The area was an isolated part of the young city of Denver. Mt. Airy and other private sanitaiums were always located in the boondocks. In that day families felt the need to hide their relatives, and some still do0 There was that stigma then that shadowed institutions, that there had to be a buffer from the neighborhood.
Several psychiatrists devoted their finances and efforts to the facility when they could freely evaluate, revise and adapt new treatments. By 1930 Drs. Sidney Bluemel and Leo B. Tepley became sole owners of MAPC. These men and their associates understood mental illness, but few laymen understood mental patients and their psychiatrists. Bluemel, in a biography written by his wife was described as "The gentle crusader". For he had insisted his
8


patients be treated humanely and with empathy He revised psychiatric jargon to common, understandable terms such as "anxiety" and "indecision". He sought a language that would imply the truth that abnormal behavior was both temporary and curable.
The ageing Bluemal; and his dream of a modern psychiatric hospital only paritally fulfilled was forced to relinquish Mt. Airy in 1952. Denver's 18 existing psychiatrists rallied to Mt. Airy's rescue. The plan was to purchase and operate it as a group. The Mt. Airy Foundation needed 21 trustees to be economically feasible, so two neurosurgeons and a neurologist were inlisted to fill out the complement of physicians. In 1958, 18 community leaders were added to form the Board of Governors to operate the non-profit hospital.
A lot of psychiatric therapy has been developed at Mt. Airy over the years. Some of the initial research work with antabuse in treating alcoholics was conducted at Mt. Airy. Although it had other mental patients, it was known in its' early years as a rest home for alcoholics. Denverite Mary Chase was no doubt thinking of Mt. Airy when she referred to "Dr0 Chumley's rest" in her 1944 play, Harvey. The main character, Elwood P0 Dowd, was a lovable alcoholic who talked to an invisable six foot rabbit named Harvey.
Dr. Edward G. Billings, one of the original trustees in 1953 admits that the early therapies, although the best available at that time, were quite primitive compared to present day treatments0 "There were few psychotropic drugs and we depended on physical therapy, massage, wet packs to wet tubs".
a north wing in the early 1350s.
9


Dr. Billings feels that psychiatry today is not too far removed from its' original basic principles with changes being only in the area of improved therapies.
Mt. Airy's liaison with the C.U. Medical Center since 1934 has exposed the facility to some of the top people in the field of psychiatry and as a result is responsible for creating the level of psychiatric treatment that is superior to many areas of the United States, except for a few large coastal citieSo Mt. Airy reflects that expertise and progress. The staff of 18 psychiatrists in 1953 has grown to nearly 300 affiliated with the hospital in 1982.
Mt. Airy is now a modern hospital with the latest equipment. Its' west wing completed in 1867 at a cost of 1 million dollars and a connected east wing in 1975 for 1.8 million dollars. The facility is quite functional in comparison to other similar facilities but admits that it does not reflect some of the needs and ideas that they would ultimately like to see realized; also expansion of new and supportive activities are severly limited.
The hospital is modern with the latest equipment. The West Winn completed in 1967 at a cost of $1 million and the connected East Wing completed in 1975 for $1.8 million.
10


Mt. Airy is well known for keeping pace with the present and examining the future. Programs are evaluated and changed yearly as a continuing growth process so that new concepts and programs may evolve for the patient's benefit. Two of Mt. Airy's inovative programs with respect to adolescents are as follows
In 1974 Mt. Airy began an educational program for its' patients with the hiring of Mary Loir Munroe, Director of Education and then faculty member at the University of Denver School of Education. She was hired as a consultant to devise an education program for the youngsters admitted. Up till that time they were without. Rarely would a school send over a homebound teacher. Mt. Airy's view point was that the school districts had a responsibility for the patient there just as they do for a student with rheumatic fever or a broken leg, and even more so since the patient may spend anywhere from three months to 1% years at the facility. It was felt that they had the same right to a normal life experinece and that included an education. It was a difficult task to convince the school districts but it was accomplished. An added benefit of this new program went to the schools, for it helped the schools accept and understand more about mental illness and how this understanding could carry on into the system and community. Denver and Jefferson County school districts now assign permanent teachers to Mt. Airy and other districts send home bound teachers when their students are admitted. They get a full curriculum except labs and presently graduate up to 10 patients per year
In 1978 a living skills program was intoduced such as how to open a bank account, how to apply for a job or obtain an apartment. Through this program they learn the practical aspects of daily living, the things they need to be self-sufficient. The program has been so successful that a similar program is in full implementation with the adult patients.
Psychiatric Service Facilities Defined
In order to design a specific psychiatric treatment facility it is important to identify and understand the numerous types of facilities presently in existance. Such facilities fall into 5 major groups, and are defined as follows:
11


1) Community Mental Health Centers
2) Psychiatric Outpatient Clinics
3) Psychiatric Services in General Hospitals
4) Private Psychiatric Hospitals
5) Public (State) Psychiatric Hospitals
1) CMHCs gained support by an Act of Congress under the CMHC's Act of 1963 and since then hundreds of such centers have opened to provide treatment for those with mental illness in the community and provide preventive services. Millions of local, state, and federal dollars have been provided under this federal law to build and staff such centers to serve all citizens in the surrounding population areas of 75,000 to 200,000 persons. Such centers presently number over 400 and are based primarily upon social psychiatric care concepts. Many are operated in conjunction with general hospitals
CMHCs are located where the people are, near their families and places of work-making possible preventive intervention, early treatment, and appropriate care. Such centers may operate in one building or combine the services of several facilities. Services are coordinated in an overall program providing patients with continuity of care, suited to the course and degree of their illness. This feature is cardinal in treating and restoring those who suffer any form of mental illness0 In such centers patients can recieve hospital care, day care, outpatient care and emergency services. An advantage of this system is that offered follow-up services help in the patients rehabilitation and receiving support. Most of such systems (centers) operate on federal and state funding and the patients ability to pay such as a sliding fee schedule.
Such center's aesthetics to program offerings vary according to the affluence of the locale but are generally low key in a physical sense and strive for social acceptance of their operations.
2) Psychiatric Outpatient Clinics such clinics are usually private for-profit systems operated by one or more attending psychiatrist in conjuntion with other supportive therapists The physical setting is typically a medical office building or a small building complex housing a group of psychiatrists set up
12


to offer such services. The psychiatrist who functions as director is responsible for providing diagnostic, consulting, and therapeutic services for outpatients with the help of a limited professional staff that often includes psychiatry, psychology and social work. Other support services are usually provided as needed by representatives of related disciplines such as pediatrics, neurology, and speech therapy etc. This justifies the medical office building setting.
The premise of an outpatient clinic is that it serves patients for whom appropriate such psychiatric assistance in this setting may present more prolonged illness. It also serves those recovering from a stage of illness that required hospitilization and provide further outpatient care as they resume a regular way of life.
3) Psychiatric services in general hospitals are usually limited and small in size, often converted medialc-surgical units of less than 60 beds. Treatment tends to be symptomatic and relies on psychopharmacology and crisis intervention to a greater degree than CMHC's, clinics or private psychiatric facilities.
Because the psychiatric patient is different from the patient that a general hospital is designed and staffed to accommodate the result is to treat the symptoms rather than the etiology of the disorder. Such settings rarely provide the space, staff or programs to effectivelyiseparate psychiatric patients by age or level of care0 The major function of this type of facilities units is to stabilize the patient and discharge or refer him to another agency as quickly as possible. Their purpose is not to provide long-term treatment or rehabilitation.
The problem with general hospital psychiatric units (system) is that the patient is quite ambulatory to the setting is designed to serve non-ambulatory patients. This means that the patient is artifically restricted which is detrimental to his transition back to a normal style and funcitioning of life.
4) Private Psychiatric Hospitals are nongovernmental specialty hospitals.
Similar to general hospitals, they are operated on either a non-profit of for-profit basis. They provide treatment programs with definitive goals for the welfare of the patient with the knowledge that the period of hospitalization
13


may be only a segment of the total treatment plan. These facilities generally serve a clientele of middle class individuals with moderate to excellent insurance policies, or the very wealthy.
The physical stature of such facilities vary but generally give the appearance of an institution in major inner city spaces which require stacking of function due to zoning codes and limited sq. footage to work with. Other facilities built in "the boondocks" exhibit a campus attitude and often elude the title of "Psychiatric Facility" by referring to themselves as speciality schools. Some of these type of facilities also refer to themselves as "Residential Treatment Centers". Most private psychiatric facilities serve their geographic communities local, state, and regional. A number of these hospitals, because of their special or unique treatment programs for specific categories of patients, recieve referrals from all over the country. Also to be noted is the duration of stay at these facilities. Some are classified as short to moderate term (2 months to a year) and others as long term (1, 2,
3 yrs. or more). The later being the most serious or more cronic cases. Most long=term private psychiatric hospitals operate as a closed system utilizing all in-house staff with Doctors including their own private educational system. The short to moderate term hospitals try their best to keep as much community contact and resource utilization as possible to provide a more normal, healthy environment for the patient.
The primary goal of this type of hospital treatment is not always the shortest possible stay but the most effective therapy. The private psychiatric hospital offers probably the most intensive, wide range with variety of treatment programs in the field (Occupational Therapy; Therapeutic Recreation;
Living Skills; Education, to name a few).
5) Public Psychiatric Hospitals are usually defined as institutions provided by the community wheter it be the city, county, state or federal gevernment. These public facilities provide both short-term and long-term treatment and admit patients both voluntarily and by logal committment while others generally do not get involved with committments.
r
14


The facilities are generally looked upon by the public with fears of the past. Many of the facilities still in use were a product architectually, of the 40's, 50s and early 60*s and have only had moderate cosmetic changes (people warehouses). The few public facilities built in the past 15 to 20 yrs. have had the fortune of following the conceptual lines of community Mental Health Centers.
Some feel that is is the public psychiatric hospital that houses the systems failures. That is the systems failure to provide effective humanistic treatment for the patients. For many, this is where they shall live out their lives. Many of these facilities still operate in a large scale to promote ward concepts. Some are still custodial and have been kept that way thru personal and political interests and fear.
5) Public Psychiatric Hospitals usually operate on a closed system with regards to staff and Doctors. Many continue to promote a fully locked restrictive system as the patients environment. Others promote an open door policy which has proved to be far more effective than the first popular system. Many of these facilities are still located in peripheral areas.
Current State of Industry
At this stage it is important to review graphically examples of current, prominent, and proposed psychiatric facilities. From this, one can derive the present state of Form, Order, Size and Relatibe Cost. Unfortunately due to personal and political pressures on a federal and state level, the momentum gained in the middle and late 60's was greatly diminished in the middle and late 70*s. Very little new construction in psychiatric care facilities has been completed in the last part of the 70's to the present. Many facilities are trying to make do with what they have thru cosmetic alterations and moderate additions. Construction costs and financing of Health Cafe Facilities in general have also retarded the industry. To add to this, strict code requirements inhibit proper design because they do not provide acceptable exceptions in the case of supervisory care facilities (psychiatric type facilities).
15


The following is a list of the examples in order of their presentation. Note: Areas depicted in plans focus on areas relevant to the project and not all portions of each facility.
Current Facilities
#1) Mount Airy Psychiatric Center, 4455 E. 12th Ave., Denver, CO 80220 (303-322-1803) Type: Hospital, private, not-for-profit. Total sq. ft.=92,789. Total beds=100. Total sq. ft. per pt.=927. Average cost per pt. day=$258.10. Treatment type: Open referral admissions and Dr's. Length of stay: Short to moderate term. Age range: Adolescents to geriatrics. Current state of the industry
//2) The Browns Schools "Oaks Treatment Center", 1407 Stassney Ln.
Austin, Texas. Type: Campus, private, for-profit. Total sqa ft.= 49,000. Total beds-126. Total sq. ft. per pt.-389. Average cost per pt. day=$275.00. Treatment type: Closed in-house system of Dr's Length of stay: Moderate to long-term. Age range: Adolescents.
#3) Timberlawn Psychiatric Hospital, Inc., 4600 Samuells Blvd., Dallas, Texas. 75223. Type: Campus, private, for-profit. Total sq. ft.= approx. 147,000. Total beds=168. Total sq. ft. per pt.=875.
Average cost per pt. day=$265.00. Treatment type: Closed in-house system of Dr's. Length of stay: Short-moderate and long-term.
Age range: Children to geriatrics.
#4) San Antonio Childrens Center, 2939 W. Woodlawn, San Antonio, Texas
78228. Type: Campus and residential, public, not-for-profit. Total sq. ft.=approx. 75,000. Total beds=6.4. Total sq. ft. per pt.=1,171 Average cost per pt. day=$150.00. Treatment type: Closed in-house system of Dr's. Length of stay: Short ot moderate-term. Age range: Children to adolescents.
#5) Brady Hospital (R.M.H.S., Inc.), 2135 Southgate Rd., Colorado Springs CO. 80906. Type: Hospital-semi campus, private, for-profit. Total sq. ft.=approx. 54,000. Total beds=83. Total sq. ft. per pt.=650. Average cost per pt. day=$300.00. Length of stay: Short to moderate term. Age range: Adolescents to adults.
16



7n
#6) McLean Childrens Hospital, Belmont, MA. Type: Campus-University supported system. Total beds=40, Basic structure: Reinforced concrete exterior and interiors. Designed for austistic children.
Other data not available. Age range: Children.
Proposed Facilities
#7) Cedar Springs Psychiatric Hospital (H.C.I.), Colorado Springs area. Type: Campus, private, for-profit. Total sq. ft.=56,000. Total beds=86. Total sq. ft. per pt.=651. Average cost per pt day=$319.00. Treatment type: Closed in-house system of Dr's. Length of stay: Moderate to long-term. Age range: Adolescent to adults. Proposed cost for facility=$8,750.958=$156.00 per sq. ft.
#8) Bethesda Hospital, Denver, CO. 20 bed addition for adolescent and pre-adolescent. Addition=22,400 sq. ft. boosting facility to 110 beds. Proposed cost for addition=$3,622,586=$161.00 per sq. ft.
#9) Proposed Mercy Highlands Ranch Medical Center in Douglas County
(Plans not shown). This data is presented to show the cost difference between a Medical and a Psychiatric facility. Total beds=125<> Total sq. ft.=141,654. Total sq. ft. per pt.=1,133. Average cost per pt. day=$693.90. Proposed cost of facility=$34,276,249=$242.00 per sq. ft.
17




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MT. AIRY PSYCHIATRIC CENTER
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2nd Floor Adolescent Units E&W
20


MOUNT AIRY HOSPITAL
- NEW WING ADDITION
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22




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LEGEND TO SITE PLAN
BUILDING NUMBERS BmTDTMG existing site
1 Convalescent Building
2 Brower Cottage
3 Recreation Hall
4 Brower Annex ,
(Classrocms)
5 RiceHouse BRADY HOSPITAL
Program Development 1982
33


rx
Brower Cottage East & West
34


3 d Floor
35


EX:6
Hall Mercer Childrens Center, McLean Hospital, Belmont Ma
36



Legend
Kitchen Dining room Conference room Living room
Adjunctive therapy room
Staff
Household therapy
8 Activity area
9 Double bedroom
10 Single bedroom
11 8 Bed sleeping
MAIN FLOOR PLAN
37


Parkside Drive
126 Parking Spaces
Cedar Springs
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1 3 KITCHEN
14 LIBRARY
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17 MEDICINE
1 9 OFFICE
1 9 NURSE STATION
20 LOUNGE
2 1 20 BED SUITE
22 LOBBY
29 OUTDOOR COURT
41
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Evolution of Project
^7

In the summer of 1981, Mt. Airy was again turned down by the Denver City Council on a request to rezone some of its' property to hhe north of the existing hospital. Ths hospital's need and ability to expand programs, to add new programs such as a badly needed childrens' unit or to meet out door recreation needs (per Joint Commission suggestions) becomes severly limited given city council's reluctance to allow rezoning or property currently owned by the hospital. As a result Mt. Airy was only allowed to improve its' support functions such as: records, business, interview space, a new OT clinic and some indoor activity space. In the fall of 1981, discusssions began between Rose Medical Center and Mt. Airy to determine if it was feasible to conduct programs jointly on Rose's campus. Such discussions were necessary, for the increasing demand for psychiatric services and beds on the current system has forced it to operate at capacity for the past two years. A study compiled by Mt. Airy supported the obvious need for more programs and beds to the tune of at least 150 new beds by 1985. Approximately 80 organizations and prominent individuals in the field concurred with these projections. But in its' talks with Rose it quickly became apparent that Rose was as landlocked as Mt. Airy.
The talks resulted in the concept of a joint venture in a new south campus that would house a 125 bed facility (approx. 105,000 sq. ft.). The new hospital shall provide the badly needed specialized programs of care for childre, adolescents, adults and geriatric patients including a newly conceived psychiatric medicine unit. Although Mr. Airy is known as a modern up to date psychiatric facility with programs to match, it fails in conveying the positive aspects of treatment due to its' physical stature (interior and exterior). Its' physical and functional relationships still imply "institutional treatment".
This is not a criticism of the facility per-say because it was built in phases as they began to evolve the concepts of normalization of the psychiatric environment. Mt. Airy has a committment to itself and the community to convey this newer and more pronounced concept in its' new proposed facility.
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The development of this new facility is a coordinated effort of the two hospitals in conjunction with specific requirements of the Joint Commission, National Institute of Mental Health, Colorado State Health Department and Douglas County, Building, Fire and Safety codes.
JUSTIFICATION
Justification for the facility
At least 2,000,000 of our youngsters under eighteen need immediate psychiatric care. N.I.M.H. estimate is considered by that Institute and most mental health professionals to be a conservative fugure. There is no way of determining how many of these children and youth would have been spared their suffering if they had had available to them the broad range of services
and programs that should be available. No doubt the number would be less.
But of what benefit are conjecture and hidsight to the tragic reality of today. The needs of these children must be met. Their needs include a wholesome and normal environment, good physical care, emotional support, education, and all the rest of lifes' experiences, "To not experience, is to be dead a
body without life". In addition, these children often need services which are
more specialized, intensive, and fitted to individual needs. At present the majority are not getting this care, treatment, and services such as can be offered by the proposed new treatment units.
Justification for the project
Presently there is little, if nothing, being done in the way of interior design for psychiatric facilities, especially in the area of Child and adolescent units. Mt. Airy surveyed the countrys' architectural firms and came up with only a handful who specialized in hosptial design. Of this group, it was found that of the psychiatric facilities they had designed, most resembled general hospital facilities. They did not reflect the program needs within, nor improved outward public image.
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The "New Wave" towards normalization of the psychiatric environment invites a unique opportunity for Interior Design to contribute to the increased well-being and positive prognosis of the psychiatric pt. It also invites an opportunity to develop a more conducive treatment atmosphere for the community and those who work in the field. Its important to note that one out of every twelve persons in this country will need psychiatric treatment at some point in their lives. The overall result has monolithic implications toward a "Healthier and more productive country". This is extremely important in our present time, as our society, our county becomes increasingly fragmented.
Final Note: An interesting point of comment is that for a country that prides itself and places so much emphsis of the value of its youth for a better future, it has rarely gone beyond the level of talko Psychiatric Child & Adolescent care has always been placed at a low priority level. They are most often the target for "hand-me-downs (space wise)" & "left-overs (money wise)". Society simply does not practice what it preaches. It is time that it did.
Facilities Present Position
Mt. Airy has presently proposed an architectural schematic design for their new facility. Due to the fact that the Colorado State Health Dept, rejected their petition for a "Ceritficate of Need" it is important to note that Mt. Airy has expressed intrest and readiness to accept new systems devised to provide solutions to their goals for the Children and Adolescent Units in their new facility. This document shall provide them with new and innovative design concepts that may be used by them in future proposals or other outside interest.
PROBLEM STATEMENT
Description of Project
The problem is to design both a Children's and an Adolescent's treatment unit that will provide a more conducive, normalized therapeutic environment.
Also to be of focus for design is an area defined as "Therapeutic Services Center", which has a direct relationship to the effective treatment of the above named units. Such a center will include 1) Occupational Therapy 2) Education Dept.
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3) Therapeutic Recreation. Conceptually all three areas must interface with the remainder of the hospitals treatment units and support services.
The Children's unit shall house 15 beds (ages 6 to 11) and encompass approximately 9,000 sq. ft. The Adolescent unit shall house 40 beds (ages 12 to 18) and be split into two sections as per hospital request and encompass approximately 22,000 sq. ft. The Therapeutic Services Center shall encompass approximately 19,000 sq. ft. Total design space equals approximately 50,000 sq. ft. This figure does not inculde the requested 8,600 sq. ft. of secured activity space that shall be considered later in this document.
Scope of Project
Scope of the project shall include all areas directly realted to the specified treatment units and their functions, for as stated above they must interface with the rest of the facility. This shall include the hospital's general admissions area and adjunctive therapies: OT, Ed, and TR. The project shale include finishes, furnishings and fixtures as they relate to their function and desired qualities on each of the three treatment units. To a minor extent the project shall also include finishes, furnishings and fixtures in adjunctive therapy areas. This project shall not include specifics such as the structural design of the envelope except for minor reference to it. Nor shall it include detailed lighting and mechanical systems.
Design Objectives
A. The Children's and Adolescent's treatment units shall be designed to accomplish the following objectives:
1) To design a space that is a healing environment that is as close
to the youth's life experiences as possible, psychologically and
physically, yet meet the needs of an institution.
2) To develop a space that will smooth the transition from home to
institution,,
3) To Communicate trust and confidentiality to the pt. thru respect
of the pts' need for privacy, mentally and physically.
4) To provide an environment that does not isolate the pt. physically
or psychologically from the treatment agents.
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5)
6)
7)
8)
9)
10)
ID
12)
13)
14)
To Communicate to the pt. that "Here" is a space, where they
can feel safe; experience and identify their emotions and causative factors; and that "This" place is going to help tham deal effectively with the situation that brought them there to begin with.
To Communicate to the patents that they can feel safe about their child's new temorary life space thru a trusting relationship with staff and the therapeutic spaces they come in contact with.
To provide a more protective environment for the patient who
needs more obvious boundries as measured by the level of precautions due to 1) Risk to self and others 2) Court custody 3) Extreme runaway behavior.
To Communicate to the pt0 that if he can't control or loses control of his behavior, this is a place where he can learn controls and sometimes be assisted with that control safely, if the need arises.
To provide the patient with a structured daily schedule and environment which decreases disorganized, inappropriate, or hyper-active behaviors as measured by graded diminution of such acticity.
To provide an environment that will encourage an active participation of the pt. and interaction with staff and other pts. throughout their stay in a controlled environment.
To design the treatment units so as to respond to the sense of "inherent expected responsibility level" of the "designed for" aged grouping.
To provide the patient with an opportunity to utilize Occupational Therapy (OT), Therapeutic Recreation(TR), new or continued academics (ED), plus social interaction and living skills conducive to normal child and asolescent development.
To create an environment that is resistive to the typically destructive nature of children and adolescents I
To provide an environment that responds technically to human physiological factors such as light, color, sound and texture.
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15) > To motivate a change in public attitudes towards psychiatric
facilities away from the stereo-typed institutions of fear, to community need and willing acceptance,
16) To provide a facility that meets and exceeds requirements set
forth by 1) Joint Commission, 2) National Institute of Mental Health 3) Colorado Dept, of Health 4) 1982 Uniform Building Code
5) National Fire Protection Association "Life Safety Code 101",
B. Adjunctive therapy spaces (Therapeutic Services Center) shall be designed to accomplish the following objectives in their designated divisions:
OT
1) To provide an environment for activities that stimulate the
development and refinement of fine motor abilities through movement experiences involving various forms of small object manipulation.
2) To provide an environment for activities that encourage the
development of acceptable forms of peer relations such as taking turns, sharing, and working together.
3) To provide a space where patients may experience a wide range of
arts, crafts media and possible new trade interest or avocations (advantaged by adolescents and adults primarily)
4) To provide an environment that will encourage enhancement of self
esteem through challenging and self reinforcing activities.
5) To provide a sapce where patients may effectively become involved
in a comprehensive Living Skills Program, which will initiate, promote or redevelop skills in the area of cooking and nutrition, public social interaction, budgeting, vocational preparation behavior skills needed to increase independence with daily living tasks.
6) To provide a space sensitive to the task of sensing integration
therapy.
Education
1) To provide an environment that affords opportunityes for the re-
inforcement of a variety of academin concepts and their integration with concepts dealt with during the course of the school schedule.
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2)
3)
4)
(TR) 1)
Such opportunities fall into the following areas; number concepts, language, arts, science, social studies, arts & crafts, library resources, and appropriate living skills.
To provide an educational environment similar to what the adolescent pt would encounter on the outside.
To provide a controlled graduated classroom environment to
meet the needs of a child who may be experiencing first exposure to school.
To provide an environment for the development and refinement of perceptual abilities through a variety of perceptual motor experiences utilizying: visual, auditory, tactual and kine-thetic cues.
To provide an environment that affords opportunities for the release of excess energy stress and emotions in an acceptable manner thru striking activities, running, jumping and climbing.
2) To provide spaces that stimulate the development and maintenance
of an enhanced level of fitness, involving the elements of: muscular strength and endurance, circulatory-respiratory endurance, flexibility, power, speed, agility and balance,
3) To provide spaces and programs that promote exposure to the "Arts";
stage, theatre, drama, music & dance, such as to increase normal social interaction in future public places,
4) To provide activity space and programs geared specifically
towards Psychomotor development in the child patient.
5) To provide controlled outdoor activity spaces for those children
in adolescent pts. who need more obvious boundaries as measured by extreme runaway precautions.
Design Issues Addressed
A. Human/Psychological: Design should maximize treatment programs associated with specified age and developmental levels, through active and passive participation and experiences provided within. Specific issues to be addressed fall under the following five needs. These five needs relate to
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the origins of the disorders presented to the system for correction.
Needs
1) A wholesome normalized environment.
2) Good physical care.
3) Emotional support.
4) Education
5) Experiences that motivate personal growth.
These five needs are an update of A.H. Maslow's defined basic levels of human needs. Maslows list included the following.
Hierarchy of Needs
1) Physiological (hunger, sex, thirst, sleep).
2) Safety (from injury, in unfamiliar surroundings, etc.).
3) Love and affection.
4) Self-respect and self-esteem.
5) Self-fulment and self-actualization.
Maslow assumed that the "physiological needs", pertaining to the drives just considered, such as thirst, hunger and sleep were the lowest or most basic aspect of human motivation and functioning. When the needs at all levels are unsatisfied, these are the strongest, but if the physiological requirements are met^i then the safety needs emerge, such as the desire for security, protection, and freedom from danger. Love and belonging, next in the hierarchy, included the motivation to have friends, companions, a family and an identification with a group. As these needs are satisfied, self-esteem motives become important, involving the desire for respect, confidence and admiration. At the esteem level, presumably the desire for affectionate relationships has been fulfilled, and then achievement, superiority, and prestige motives become improtant. At the highest level is the desire to fulfill one's personal capacities, to develop his or her potential, and to do what one is best suited for as well as he or she can. This level is called self-actualization.
An example of this level would be a person with a tendency for mothering who becomes a good mother, individual with leadership qualities who assumes a role in government or an artist devoted to his painting. Needless to say,
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among the few people who may be appropriately called self-actualizing, most of them self-actualize only from time to time. The concept of self-actualizing is closer to an ideal than an actuality.
To recap, the higher level needs (#3 to 5) emerge when lower level needs (#1 & 2) are met. The most basic consequence of satiation of any need is that this need is submerged and a new and higher need emerges. Many facilities in the past and some presently assist patients in meeting only their physiological and safety needs. This is considered to be custodial care only. For some patients even these two basic needs have not been met on the outside. The most progressive treatment facilities attempt to fulfill the last three levels of needs by increasing the capacity of the patient to meet these needs themselves.
Physical Issues
B. Factors relevant to the design of interiors in the "New Order" of psychiatric hospitals include:
1) Functional orientation of space.
2) Appropriateness of space for intended use.
3) Optimum sq. ft. required of specific space for intended use.
4) Adaptability of space for activities.
5) Traffic flow designed to facilitate movement (sequence) and involvement of pts. and staff within and to the outside spaces.
6) Specialized treatment areas such as education, dining, living spaces, recreation, occupational therapy, living skills, private psychotherapy, nursing station, dispensing of medications and admissions.
7) Maximized relationships between the interiors and the outside world (open visually).
The scope of physical considerations and limitations in the design of a Psychiatric Hospital are tremendous. Several guidelines have been developed over a period of time from many different sources with respect to; treatment programs, functional orientation of spaces, life safety features, minimum and maximum allowable sq. footages. A number of these guidelines have found their
50


way into the form of : Building Codes (UBC 1982), Life Safety Codes (NFPA 101), Joint Commission Accreditation Manual for Hospitals, and State Health Dept. Hospital Guidelines. Relevant excerpts from the above are contained in the appendix under seperate cover. The following condensed guideline of spatial needs provides a quick overview for study and was developed by the "National Institute of Mental Health", Bethesda, MD., in 1978. The two charts that follow were developed by Edward T. Hall and show the interplay of human distance and immediate receptors in proxemic perception. Additional major physical considerations primary to the program have been derived from analysis of existing facilities and present themselves later under "Facts & Space List".
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SPATIAL NEEDS OF PROGRAM ELEMENTS
NOTE: Design of ail spaces should be noninstitu-tional. The following are suggestions for consideration in all program element needs indicated below:
Openers in space-planning
Live plants
Design for groupings of 4 to 8 persons
Comfortable light level (natural light, desk lamps, incandescents instead of neon, etc.)
Freedom for hanging pictures
Warm surface finishes in natural materials
Views outside
Contact with outdoors
Visual access to mainstream of activity.
The following does not assume that all services must be located under one roof (see Location of Services).
1. Inpatient Unit
This is a short-term residential facility for living under a supervised therapeutic program, requiring a domestic or college-dormitory rather than a hospital atmosphere. Architectural Section, NIMH, recommends this area be classified residential occupancy (NFPA No. 101) where permitted by local authorities.
Patient Needs
Privacy for sleeping, dressing, and bathing.
Provision for personal grooming needs.
As few regulations for use of facility os possible.
Patients should be able to rearrange furniture, hang pictures on wall, etc.
Patient belongings should not be out of reachlockable storage space should be provided in each patient's bedroom unless specifically prohibited by program.
Domestic Needs to Be Provided Laundry and snack kitchen for use by each living group (16-24 patients).
Socialization Areas A variety of settings is necessary:
Space for small conversational groupings or quiet individual use (2-4 persons). Example: small living space in a suite of two or four bedrooms.
Activity spaces for games, dancing, music, group living (16-24 persons). Two living areas are desirable to allow noisy and quiet activities to occur simultaneously. Quiet activity space could also be used for group therapy. Example: a lorge living room as the focus of living group activities with a smaller, comfortably furnished lounge odjo- 52 cent.
Visiting Area Space should be provided for private visiting with family and friends. Example: an out-of-the-way alcove for 6 persons, located near the entrance to the unit and the nurse's station, allowing visual and conversation level acoustical privacy.
NOTE: each group of 16-24 patients requires the above spaces. Design should allow natural groupings of 48 persons.
Recreationphysical exercise Space in the form of an exercise room, gymnasium, or outdoor space (especially in warm climates) should be provided. Example: small exercise room for group settingup exercise program with agreement to use high school gym and playing fields located within easy walking distance.
Staff needs
Lounge area
Storage for personal property
Staff toilet
Area for charting/private discussion with therapists
Security for drugs
Multiuse patient interview space, family discussion, etc.
Minimal barriers to interaction with patients. Example: desks are preferable to glazed nursing stations.
Housekeeping Needs
Domestic housekeeping:
Linensin patients' bedrooms or locate for central distribution
Each bedroom unit to have own linen supply Bathroom and personal items Central janitor's closet Dietary services:
Snacks, patients' activities in kitchen Feedinghospital cafeteria and kitchen service on units; storage for dishes, linens, etc.
Icemakers
Complete domestic kitchenexhaust system must be adequate
Intensive care
Acoustical privacy
Social space for contact with staff and freedom to leave confined room Close supervision by staff Controlled access to toilet, wordrobe, light switches outside patient's room Security
Tamperproof equipment and fixtures within patient's room and toilet (but not obviously tamperproof to patient)



Tempered plole gloss or removable-type detention screens
Treatment roomfirst aid, emergency physical examination items for special programs such as drugs, alcohol, etc.
Laboratory with storage
Direct access from nurse's station and from emergency rooms in general hospitals
Audio communications between nurse's station and patient's room
Patient rooms may be used for medical core when needed.
Necessary equipment not removable from the room must be lockable and concealable. We recommend occupancy for this area be institutional.
2. Emergencies
Emergency can occur in any element of service at any time. Most common:
1. walk-in
2. escorted emergency
Walk-in: arriving at any element of service for the first time to get help. This person may come in alone or with others. He [or she] is ambulant and functioning.
Escorted emergency: ambulant but not functioning.
Physical Space for Walk-in:
Inviting entrance
Must have immediate relationship to outside while patient is in waiting-reception area Privacy with receptionist in stating his [her] needs
NOTE: all spaces for walk-in interview and initial treatment, admitting of walk-in emergency can be those used by outpatients.
Escorted emergency
Will utilize all staff and space in emergency suite of general hospital.
Additional spaces may be needed in general hospital emergency.
Space:
Interview space that promotes communication between patient and physician. Holding spacewaiting bed spacefor patient to wait while disposition for treatment is considered (i.e., sedated patient). Entrance available directly to intensive care area for escorted emergencies.
NOTE: design and location should motivate interaction and communication between all agencies and elements of service utilizing the facility.
3. Outpatient
Admitting Offices Should be convenient to re ceptionist
Ancillary Services Woiting areas Secretarial space
Public and staff toilets, lounge (coffee, sink, refrigerator), and library-workroom
Waiting Areas
Limited to 8-12 patients Distributed throughout office areas Receptionist by front dooropen, friendly, encourage contact between receptionist and patient
Office space Conference and interview Meetings (with consultation ond educational service)
Play therapy Group therapy* Larger groups
Individual Staff conference! Community groups
Family Interagency professional groups General meetings
* Group therapy rooms to be utilized through total programs
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a
a
/
Children'! Treatment Adjacent to entrance and child therapist's office Provide for observation
Provide for work sink (as part of "messy area"), and locked storage
Provide for separate toilet available to children; separate waiting area, with possibility of observation by parent; outdoor play space; scaled for children; cleanable surfaces
Office Space Should motivate communication between patient and therapist, should contain doctor (staff) and at least four or more patients and be flexible in arrangement of furniture.
Conference Spaces
Sufficient to accommodate 16 people Suitable for audiovisual presentations, staff meetings, staff work area Accessible to main entrance and/or office spaces and rest rooms Suitable for group therapy Provides storage closet
Staff Lounge Should be comfortable for 8 people adjacent to staff toilets, storage, and small kitchenette (coffee-making, lunch, refrigerator); also adjacent to staff library and workroom.
Need for large meeting roam depends on availability of space in the community. Such a room needs audiovisual facilities, storage space, and sufficient toilet areas,- it should be located between central facilities and community.
4. Partial Hospitalization
Day Caro This requires a primary social area (living-room-type space)
1. Staff needs
Office space for day program director
Work area for staff
Medications
Nurses' lockers and toilet
(All located in position for information and
control for particular hospital program)
2. Patient's needs
Storage for wraps and for personal articles
Telephone, drinking fountain
Toilets
Kitchen suitable for social groups and therapy
Occupational Therapy This consists of quiet and noisy activities and depends on the program. The most flexible design requires at least two rooms of classroom size with two kinds of storage: for patients' projects and materials and for equipment. The office for the program director is mostly program space for patient occupational therapy activities with the occupational therapist as part of the therapy team. It may be without staff offices and consist of large rooms divided by movable storage cabinets. 54
Recreational Therapy Social recreational therapy has the following requirements:
Large social space
Outdoor terrace for gardening, outdoor games, and an inactive outdoor area for quiet T.V.music Quiet indoor space Movies
Kitchen, canteen-type Library (quiet)
Quiet social area
Not minimal but desirable are a swimming
pool with its own dressing rooms and toilets; and table games.
Structured recreational therapy programs require a small gym, for 8-12 patients at one time, with its own showers, dressing rooms, and lockers. One should inventory the community facilities that con be used: YMCA, schools, shopping centers, public parks, public pools, and other mental-health related programs in the community. An active outdoor area must be available with a playing field, large space for active games, etc.
The R.T. office can be some as for O.T. Weekend and night-evening program can be held within the same space as the inpatient program.
5. Children's Day Care
General needs include a staff office, a central reception roomgathering place, and classrooms. The program could utilize the adult gym. Toilets and a small snack kitchen should be available. (They could be used for other parts of the center's program.)
Classrooms need an area for messy (wet area) work (sink, etc.), an outdoor area, a teacher's work area with a desk (no desk in classroom), and also, for problem kids, quiet study; this class is separated from main classroom area by a curtain. Children's outdoor play space must be separated from adult outdoor areas.
6. Administration
Reception-waiting area Director's officemeeting room nearby Offices for program directors Volunteers and part-time office and lounge with lockers and toilets Conference room Library-workroomstaff lounge Businesssecretarial pool Central records for all service elements
7. Consultation and Education
Meeting rooms and office spaces are located adjacent to or within central office groupings. Center can multiuse spaces for other elements of program for this purpose. (Basis of operations for C&S is out in the community ond will use facility only to conduct business and for meetings.)


CIRCULATION
1. Use for Socialization
Circulation space can be used for more than transportation from one area to another. Informal contacts, pausing along the way to look at views, stopping for a cup of coffee at a coffee bar are activities that also encourage social contact.
Entry-Waiting Aroa Entrance through the front door to all program elements located in the facility should be possible. Arriving persons should be greeted by a staff person out in the open. Example: volunteer behind a desk located in sight of front door. Waiting areas should be small groups of 4 to 6in sight of receptionist. Woiting area allows view of mainstream of activity, but is located in well-defined area out of main traffic pottern.
Drinking fountain, toilets, and pay telephone are adjacent to entry-waiting area. A coffee pot is preferable to vending machines.
Contact with Staff Staff persons (volunteers, secretaries) should be located to be visible to persons moving in circulation pattern of building. Example: secretary for outpatient offices located in alcove with chairs for waiting adjacent to circulation space.
Provide informal social areas as part of circulation space leading to meeting rooms, partial hospitalization, etc. places where numbers of people congregate, and also at "nodes in circulation systemplaces where people are likely to pause. Example: gathering space with area for coats, bathrooms outside community meeting room.
Waiting for outpatient appointments should be adjacent to outpatient staff offices. Director of Center should be located adjacent to other staff offices to encourage interstaff contact.
2. Orientation
Use of views outdoors and natural lightclear inside/outside circulation.
Clear relation of program spaces to front door: go here for outpatient, go there for day program, go around corner for inpatient.
Privacy or separation provided by single turn in corridor or by screensminimum of closed doors.
Staff person to greet arrival to program area secretary for outpatient area, nurse or volunteer located by entrance to inpatient unit, etc.
Use staff and design of circulation space rather than barriers (locked doors) for control.
3. Time ute
Locate community meeting areas near front
door for night-time use----lock off rest of
facility.
Partial hospitalization/inpatient section could have its own entronce for day/night use.
4. Variety
Circulation spaces should contrast light, dark, outside, inside, narrow, wide, free, controlled, stimulating (warm colors), subdued (cool colors) to provide clues to kind of activities associated with nearby program spaces and to maintain orientation. Example: corridor outside day program area widens to allow informal socialization and use of lockers located against one wall and is lit by skylight.
3. Zoning
Program elements should be related to:
Public accessibility
Acoustical separation
Heavy circulation/noisy activities
Quiet/private activities
Scheduled use/nonscheduled use
Frequency of use
Day/night use
Unique or common use
Sole staff use
Sole patient use
Joint use by staff and patients
Relation to other program spaces
Relation to front door
Need for outdoor space and natural light
Need for privacy/controlled access
NOTE: The prevalent dichotomy between circula-tion/service spaces and program spaces should be minimized where possible.
Physical Planning Guidelines for Community Mental Health Centers, Clyde H. Dorsett, AIA, Architectural Consultant, National Institute of Mental Health, Bethesda Md 1978.
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CHART SHOWING INTERPLAY OF THE DISTANT AND IMMEDIATE RECEPTORS IN PROXEMIC PERCEPTION
KINESTHESIA
FEET 1 2 3' 5 6 7 8 10 12 14 16 18 20 22 30
INFORMAL INTI MAT!: PERSONAL SOCIAL- CONSULTIVE J i PUBLIC
DISTANCE CLASSIFICATION <3 ( not j 0 (CLOSE I NOT CLOSE CLOSE CLOSE ( NOT ( CLOSE 3 /- jL MANDATORY RECOGNITION DISTANCT BEGINS HERE NOT CLOSE BEGINS AT X*-*0# i
CONDUCTION
THERMAL (contact) RECEPTORS
RADIATION
OLFACTION
WASHED SION A HAM h SMAV1NO LOTION-PERFUME SEXUAL OOOtS MEATH BOOYOOOt fOOTOOOt
MEAD, mVtS, THIOH1TRUNK CAN IS BOUGHT INTO CONTACT OR MLMBOS CAN ACGDCNTALLY TOUCH. HANOI CAN REACH A MANHJLATE ANY PART Of TRUNK EASILY.
HANOI CAN REACH AND HOLD EXTREMITIES EASILY WT WTTH MUCH LESS FACILITY THAN ABOVE. SEATED CAN REACH AROUND A TOUCH OTHER SIDE OF TRUNK. NOT SO CLOSE AS TO RESULT IN ACCIDENTAL TOUCHING.
ONE PERSON HAS ELBOW ROOM.
2 PEOPLE BARELY HAVE ELBOW ROOM. ONE CAN REACH OUT AND GRASP AN EXTREMITY.
JUST OUTSIDE TOUCHING DISTANCE.
OUT OF INTERFERENCE DISTANCE.
BY REACHINO ONI CAN JUST TOUCH THE OTHER.
2 PEOPLE WHOSE HEADS ARE 8' 9* APART CAN PASS AN OBJECT BACK & FORTH BY BOTH STRETCHING.
NORMALLY OUT OF AWARENESS
ANIMAL HEAT AND MOISTURE DISSrATl (TMOREAU)
CULTURAL ATTITUDE
OK
-OK TABOO-TABOO ANT I9PT1C OK, OTHERWISE TABOO TMOO,
TABOO
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T7
To
FEET 0 i 2 3 5 6 7 8.10 12 14 16 18 20 22. 30
VISION DETAIL VISION (VIS.* Of FOVEA 1*) VISION BLURRED DISTORTED ENLARGED on AILS OF IRIS, EYE BALL, PORES OF FACT. FINEST HAIRS DCTAA OP FACT BIN AT HOtMM, SZLmVNO*. PUPCTHTH CON* oniONAmASflv HAAONtAOC or mac SMALLEST BLOOD VESSELS IN EYE LOST. SEE WEAR ON CLOTHINO HEAD HAIR SEEN CLEARLY. 7 FINE LINES OF FACE FADE DEEP LINES STAND OUT SLIGHT EYE WINK LIP MOVEMENT SEEN CLEARLY ENTIRE CENTRAL FACT INCLUDED 1MMP HARJttJWV lotv^m coum HOT OftCBMOU. 1MU-C1XV VO* H4HLAA tOftUHO moi noHouNdo MUIWi JTAMOAftO 'O* DWANT VWIOM IftWlOTMO AMOU Of 1 man. OlAD ornciAMS of amciica rrt ouai A POSOH WITH JO~*0 VTUON HAJ TKKJU anno mi ft cwnow hc*jk> cru though m aim a vtju.
CLEAR VISION (VIS AT MACULA 12 HOR 3VERT) oh m Nonu CM MOUTH in*. .4 tppnc* town f*a 4.23" 1.40" UPPER OR LOWER FACT 10"x2.3* UPPER OR LOWER FACT OR SHOULDERS 20" 3' 1 OR 2 FACTS 31" *7.5 FACTS OF TWO PEOPLE 4 2" x I'd" TORSOS Of TWO PEOPLE 6* 3 r 7-TORSOS OF 4 OR 5 PEOPLE
60* SCANNING 1/3 OP *aw LM CP MOUTH AttA F*a OtSTOtTTOI NO* noACn WHOU FM3 WN *a UN- latno UPPER BODY CAN'T COUNT FINGERS UPPER BODY ft GESTURES WHOU SEATED BODY VISIBLE PEOPU OFTEN KEEP FEET WITHIN OTHER PERSON'S 40* ANGLE OP VIEW WHOLE BODY HAS SPACE AROUND fT, POSTURAL COMMUNICATION BEGINS TO ASSUME IMPORTANCE
PERPHERAL VISION HUC AOAJMJT ua- CMCAJHO HEAD ft SHOULDER! WHOU BOOT MOVEMENT IN HANDS-FINGERS VISIBLE WHOU BODY OTHER PEOPU SEEN IF PRESENT OTHER PEOPLE BECOME IMPORTANT IN PE1PHERAL VISION
HEAD SIZE ruu vnuM FKLO f*A 3VER NORMAL NORMAL SIZE NORMAL TO BEGINNING TO SHRINK VERY SMALL
%a NOTE! PERCCIjVED HEAD SIZE VARIES EVEN WTTH SAME SUBJECTS AND DISTANCE
ADDITIONAL NOTES
TASKS IN SUBMARINES
AKT 1ST y OBSERVATIONS CF GROSSER
FECPU ft OBJECTS SEEN AS ROUND UP TO 12*- IS*
ACCOMMO 0 ATTVE CONVERGENCE ENOS AFTER 15* PEOPLE ft OBJECTS BEGIN TO FLATTEN OUT
| 23 % FALL IN THIS RANGE
DIMMJCH,F.L.ft FARNSWORTH, 0. VISUAL ACUITY TASKS IN A SUBMARINE, NEW LONOON, 1PS1
ARTIST OR MODEL HAS TO DOMINATE
A PORTRAIT.
A PICTURE PAINTED AT 8* Of A PERSON WHO IS NOT PAIO TO SET*
TOON* KM A COHVU-1AJKX
BODY IS 1/3 SIZE
FULL LENGTH STATE PORTRAITS.HUMAN BODY SEEN AS A WHOLE, COMPREHENDED AT A GLANCE,WARMTH A NO IDENTIFICATION CEASE
ORAL AURAL
II
SOn VOICI CONVENTIONAL MOOIflED VOICt § § I WH'^!mATE STYU CASUAL 0 CONSULTIVE STYU
LOUO VOO WHEN TALKING FIAL PUBLIC
TO A GROUP, MUST RAISE VOICE SPEAKING VOICT TO GET ATTENTION FROZEN STYLE
FORMAL STYLE
NOTE: THE BOUNDARIES ASSOCIATED WITH THE TRANSITION FROM ONE VOICE LEVEL TO THE NEXT HAVE NOT BEEN PRECISELY DETERMINED
57


Economics
Presented here are a number of financial documents provided by Mount Airy. The first states the intital project cost for the facility that was rejected by the Colorado State Health Dept's. Certificate of Need Board in 1982. It should be noted here that "all" new proposed facilities were denied "C.O.N." due to the State's position that only 50 additional psychiatric beds are needed by the year 1990. Mount Airy's study (supported by many prominant individuals and institutions) produced evidence to indicate the need for at least 150 additional beds by 1990. Only 2 existing facilities were allowed a 20 bed increase the other 17.
The financial feasibility sheet shows the breakdown of cost for the proposed facility which summed up results in a total facility cost of $146.60 per sq. ft. This figure is well below the total cost per sq. ft. proposed by other psychiatric facilities (seen earlier) and far below the cost per sq. ft. for a Medical Hospital at $242.00. In discussions with Mount Airy's administrators it was assumed that faculity cost could reasonably be raised to a maximum of $156.00 per sq. ft. if justified. It was also noted that the originally proposed total sq. ft. did not include some essential spaces that had been omitted for special resons, but should be included in this design document.
Initial capitalized project costs are important, but more important to the patient and or the insurance company who pays most of the bills, is the yearly operating cost per pt. day. It's this cost that is most important but somewhat neglected by most state health agencies. They place more emphasis on total sq. footage per pt. and total cost of the facility rather than the savings that can be realized by providing needed therapeutic space for treatment programs. This can reduce the number of days a patient may require thus reducing the cumulative cost and burdon on society.
The second document shows a breakdown of projected operating cost (cost per pt. day). The third document shows a comparison of current changes at other similar facilities. As can be seen, the projected range of $300 to $315 per pt. day is well within the existing cost range.
58


FINANCIAL FEASIBILITY A. Project Costs
* New Construction (Total Square Feet |Q5 QQQ ) $ 9.187.500
Renovation Construction (Total Square Feet -0- ) 5 -0-
^ Site Development ? 425.000
Equipment $ 975,000
Fixed S Included in construction costs
Movable S 975,000
Architect Fees $ 769.000
Other Fees (such as soil survey, engineering, inspection, and loan insurance fees)included in $ -0-
Architects Fees Performance and Payment Bonds ? -0-
Contingency* (construction, change order, inflation) $ 961.250
Financing Fee s -0-
Consultant Costs (e.g., planning, environmental impact, etc.) s -0-
Feasibility Study s -0-
Net Capitalized Interest $ 1 ,174,941
Temporary Relocation Expenses $ -0-
Start-up Costs s 1.450.348
Bond Issue Costs:
Trustee Fee - (estimate @ 31 of SIS.000,000 loan) 450.000
Legal Fee * -0-
Printing Expense $ -0-
Title and Recording $ -0-
Rating Fee _ s -0-
TOTAL CAPITALIZED PROJECT COSTS s 15,393,039
NONCAPITALIZED PROJECT COSTS:
Required Reserves ? -0-
Other s -0-
TOTAL NONCAPITALIZED PROJECT COSTS < -0-
TOTAL PROJECT COSTS $ 15.393,039
Cain or Loss on Disposition of Asset Being Replaced $ -0-
t
These are estimates of January. 1983 costs.


C. Operating Costs
Please provide an operating budget for each department affected by this proposal for the first three years of operation which indicates fixed and variable costs. Indicate how capacity was determined. Please indicate which year is the first full year of operation. Assumed Inflation Rate 8% 8% Year l Year 2 Year 3 Hospital Total 198_5 19S_6_ 198_7_ First Full Year Fixed Costs Salaries and Wages $ 1,134,308 $ 1,408,081 $1,560,516 Maintenance $ 530,707 $ 572,911 $ 618,786 Lease $ -0- $ -0- $ -0-
Depreciation Interest Other Indirect Costs (Specify) Capitalized Interest & $ 404.089 $ 1.650.000 $ -0- $ 404,089 $ 1.650.000 $ -0- $ 404,089 $ 1.650,000 $ -0-
Issuance Expense $ 73.125 $ 73.125 $ 73.125
$ -0- $ -0- $ -0-
Other Fixed Costs (Specify) SuddIies $ 89.078 $ 108.098 $ 120.232
$ -0- $ -0- $ -0-
$ -0- $ -0- $ -0-
TOTAL FIXED COSTS $ 3,881.307 $ 4.216.304 $t4,426,748
Variable Costs
Payroll $ 4,537,231 $ 5.632.325 $ 6,242,063
Supplies $ 1,692,481 $ 2.053,867 $ 2.284,405
Purchased Services $ -0- $ -0- $ -0-
Other Variable Costs (Specify) $ -0- $ -0- $ -0-
$ -0- $ -0- $ -0-
$ -0- $ -0- $ -0-
TOTAL VARIABLE COSTS $ 6,229,712 $ 7,686,192 $ 8,526,468
TOTAL OPERATING COSTS $10,111,019 $11,902,496 $12,953,216
Projected Volume-Patient Days 32.120 39,785 41,610
Cost per patient day,
procedure, etc. 314.79 299.17 311.30
60


^7
£X
1. Projected charges for 1985 and 1986 are presented below. Also presented in parentheses are the 1982 dollar equivalents of the projected 1985 charges.
Projected Charges
Proqram (1982) 1985 1986
Child Treatment ($294) $360 S365
Adolescent Treatment ( 278) 340 345
Adult Treatment-Locked ( 229) 280 285
Adult Treatment-Open ( 208) 255 260
Geriatric Treatment ( 237) 290 295
Psychiatric Medicine ( 298) 365 370
The small increase in charges between 1985 and 1986 is possible because of increased utilization. (See Section IV.) These charges include: room and board, routine nursing, occupational therapy, therapeutic recreation, social work services, and complete school programs for children and adolescents. Pharmacy and other ancillary charges are separate, as are physician fees.
A comparison against prevailing charges in the community today demonstrates that the projected charges are reasonable.
COMPARISON OF CHARGES:
Hospital Rate Effective Oate
Emory John Brady Adult Adolescent $285.00 320.00 10/81
Boulder Psychiatric Institute Adult Adolescent $310.00 380.00 6/82
Bethesda Hospital Adult Adolescent $220.00 264.00 7/82
Colorado Psychiatric Hospital Adult Adolescent $205.00 250.00 7/81
Mount Airy Psychiatric Center Adult Adolescent $214.00 263.00 1/82
Children's Hospital Children Average for total charges per day approximately $475.00 $500.00 as of 3/82
61


'vy
7n
Time
Its been stated many times to this Designer by those in the field, that a facility should at the onset be disigned space-wise and functionally to provide program development and expansion from within and not to be tacked on later. Its this type of thinking that R.M.C. and Mount Airy wish to see incorporated in their new facility. With this thought in mind, expansion of the basic facility bed-wise is not expected. If future conditions require expansion then such should be in a horizontal fashion so as to avoid interruption of ongoing hospital operations. Special Note: Patient populations greater than that proposed (125 beds) are not suggested for they can result in increased security risk and possible adverse community response.
The following chart shows projected optimal utilization of beds. Maximun utilization should never be 100% and shall not be a policy of this facility. Experience has shown that it is unwise to fill every available bed on a unit. Empty beds allow for flexibility and the ability to meet emergencies.
-------------- Utilization ------------
Year 1 Year 2 Years 3 S 4
Program # Beds ADC - % Occup. ADC - % Occup. ADC - % Occup
Child Care 15 12 80.0% 14 93.3% 14 93.3%
Adolescent 40 30 75.0 38 95.0 38 95.0
Adult 42 27 64.3 35 83.3 38 90.5
Geriatric 14 10 71.4 11 78.6 12 85.7
Psych-Med 14 9 64.3 11 78.6 12 85.7
Total TIT" 86 70.4% w 87.2% 114 91.2%
Site with respect to time: Mount Airy has proposed the use of a relatively flat ten acre site for the hospital with ample space for a future Porfessional Office Building, parking, service, Therapeutic Recreation areas and landscaped grounds.
62


FACTS
I. Human Factors-User Profiles
Although the proposed facility is a psychiatric hospital, the number of different users, their activities and the needs of those individual users are close in number and certainly as critical as they would be for any moderate size medical facility. For practical purposed the users of this facility shall be placed into the following groups as they relate to the specified design areas. A. Clients (Patients)
1) Children-The ages to be treated shall range from 6 to 11 years of age. The disorders to be treated shall range from management and conduct disorders to acute psychoses. Those areas to be avoided but not totally excluded shall be 1) Mental Retardation 2) Autism 3) Cronic Psychoses
4) Those patients with severe medical problems.
2) Adolescent-The ages to be treated shall range from 12 to 18 years.
The disorders to be treatdd shall range from common adolescent adjustment reactions to acute psychoses. Those areas to be avoided but
not totally excluded shall be 1) Mental Retardation 2) Cronic Psychoses
3) Those patients with severe medical problems.
Addendum: "Origin of Youth Disorders"
1) Faulty training and faulty life experineces.
2) Surface conflicts between children and parents-which arise from such adjustment tasks as relations among siblings, school, social, and sexual development.
3) Deeper conflicts which become internalized within the self and create emotional conflicts within the child (or adolescent) (these are the so-called neuroses).
4) Difficulties associated with physical handicaps and disorders.
5) Difficulties associated with severe mental disorders such as psychoses. It is estimated that 80% of emotional problems are related to the first
two categories; 10% to the third category; and 10% to the fourth and fith.
63


3) Parents shall in most cases be considered patients (O.P.)since many of the children or adolescents disorders stem from them. This is not to say that they all exhibit some degree of pathology but that most are in need of assistance and guideance in dealing with their troubled child. Many will become involved in "Family" counseling and individual therapy.
The affluence of the family is important in that it provides insight to the degree of social and economic stress imposed upon the primary patient. It also provides a sense of physical possessions and accustomed needs. Most families who admit their offspring to a private psychiatric hospital are of the middle class to the very wealthy. At times a notable percentage of kids come from higher ranked military families. This is not because there is a higher percentage of mental illness among military families, but that they have the insurance that can pay for a high level of treatment and length of stay found in such a private facility. Another factor is that payment is prompt.
B. Staff This grouping includes all individuals involved with direct and indirect pt care (pt. contact). The following will list such staff by title and briefly describe their duties and responsibilities,
a. Unit Director A Unit Director is a registered professional nurse who is responsible for the direct and/or indirect total patient care service provided to all patients within a specifically assigned unit ... Duties and Responsibilities: 1. Plans, organizes, supervises and evaluates the entire unit situation in order to meet the total patient care needs of the patients on that unit. 2. Gives and receives reports, attends pre-hash and post-hash of community and gorup meeting, attends conferences with doctors, patients and staff. 3. Audits charts at least weekly and more often whenever the need arises. 4. Supervises the staff, either directly or indirectly, as needed. 5. Confers with doctors, weekly at least and then on an as needed basis, to ascertain whether or not the doctors needs and the patients' needs are being met. 6. Writes evaluations of the staff monthly on employee progress records.
64


7. Attends staff meetings on a weekly basis to meet specific educational needs and/or to interpret objectives and policies of patient care service to the staff. 8. Interviews applicants and assists in the final decision for hiring of new employees. U.D. supervises Charge Nurses, Staff Nurses, Team Leaders, Mental Health Workers I-II-III, and Unit Secretaries assigned to the particular program unit. Space Equipment and Materials Invloved: Private office with space for 3 extra persons to meet; Desk, chairs, files, and side tables.
b. Unit Consultant A Unit Consultant is a psychiatrist who is responsible for providing specialized consultative/educationsl services related to "team building" for a specific assigned program unit approx, five hours per week or more is needed. These positions are more along the lines of program directors' for the Childrens' and Adolescents' divisions ... Duties and Responsibilities: 1. To provide clinical supervision to the Unit Director at least one hour per week. 2. To provide clinical input regarding the team-building process at the weekly Program Team Meetings. 3. To attend regularly scheduled Unit Consultant Meetings with the Medical Director. Space Equipment and Materials Involved: Private office with space for 3 extra persons to meet; desk, chairs, files, and side tables.
c. Charge Nurse Plans and organizes, leads and controls patient care for each patient on the shift and unit to which assigned. Continously evaluates sympton reactions and progress of each patient in accord with the patinet care plan. Assists in patient education and rehabilitation and the provision of optimal physical and emotional environment within shift and unit assigned. Coordinates the objectives and aims of the Patient Care Services and the various programs and participates in intra-inter-department activities designed to improve service for the hospital. Duties and Responsibilities: 1. Receives report and takes pertinent notes. 2. Supervises the administration of medicines as specified in the Nursing Procedure Book. 3. Makes rounds and supervises the unit to maintain a safe environment according to the Nursing Policy/Procedure guidelines. 4. Review of patient care plans on an
65


ongoing basis. 5. Reviews written progress notes on patient charts.
6. Checks that medicine orders are reqritten in accord with legal rerequirements. 7. Assists with family problems as thh indication arises.
8. Participates in medical and psychological emergencies. C.N. supervises all Staff RN's, TL's, Mental Health Workers, and other department personnel when on the unit. Space Equipment and Materials Involved: Nurses Station and all routine daily nursing equipment such as: thermometers, baumanometer, medication equipment, special procedure equipment, oxygen equipment, external cardiac massage equipment.
d. Staff Nurse Patient care is provided by the nurse through the
use of the nursing process. This process, based on scientific principles, includes; the assessment of patients' status/nees, the formulation and implementation of a plan of nursing care to address these assessments.
The process is to assist the patient in attaining his potential level of functioning. Duties and Responsibilities: 1. Is responsible and accountable for the delivery of patinet care during the assigned shift.
2. On-the-spot assignment of tasks. 3. On-the-spot clinical supervision of staff, identification of patient care and team needs. S.RN. supervises TLs, MHWs, all Pool Staff and commercial personnel assigned to the unit. Space Equipment and Materials Involved: Nurses, Station,
nursing equipment, safety equipment, and other hospital equipment that the indicidual nurse has been trained to use.
e. Team Leader Manages and coordinates patient care for designated groups per shift. Continuously evaluates sympton reactions and progress of each patient in accord with the patient care plan. Assists in patient education and rehabilitation and the provision of optimal physical and emotional environment within shift and unit assigned. Interprets philosophy, aims and policies of administration to patients and family, hospital personnel, and allied health groups. Duties and Responsibilites:
1. Receives reports and takes pertinent notes. 2. Prepares team member's assignments according to patient condition and the stagg members' ability to perform the task necessary. 3. Provide on-going and direct supervision and teaching to all team personnel on unit. 4. Makes rounds and supervises the unit to maintain a safe environment according to Nursing Policy/Procedure guidelines.


5. Writes progress notes on patient charts each shift.
6. Assists with family problems as the need arises. 7. Assists in hospital emergencies as appropriate to training. 8. Admits, transfers and discharges patients according to the policies/procedures of Patient Care Services. Supervises MHWs and other dept, personnel when on the unit. Space Equipment and Materials Involved: Nurses Station, thermometers and baumanometers for routine vital signs as indicated.
f. Mental Health Worker Performs specific basis physical care procedures on patients assigned by the Charge Nurse in accord with the patient care plan. Records all observations on the patient's charts as specified by the Patient Care Procedure Book and patient care plan. Assists in maintaining a clean and safe unit environment for patients. Maintains routine patient care equipment in a clean and functioning manner. Reports equipment in need of repair to the Charge Nurse.
Duties and Responsibilities; 1. Attends shift report and takes pertinent notes about patients. 2. Supervises meals on unit/dining room and assists with patient needs, including meal selection, feeding, help with personal hygiene and bedmaking when indicated by patient care plan.
3. Assists in the conducting of group therapy sessions and individual milue therapy. 4. Accompanies patients to various in-house and off-grounds activities. 5. Maintain a clean and safe environment by making safety checks, covering the unit, making regular rounds, etc. patient weight twice weekly, help change linen twice weekly. 7. Attend staff meetings as assigned. Space Equipment and Materials Involved: Nurses Station, and all routine patient care procedure equipment, e.g., thermometers, scales, baumonometers, oxygen tanks, masks and catheters, go Unit Secretary Answers telephone and refers caller to proper resource person. Posts all orders including Kardex, stop dates, blackboard, patient care calendar, scheduling and requisitions. Makes out all routine unit forms. Makes daily check of all charts for proper order and adequate patient identifying information. Sets up new charts, compiles discharge charts and prepares charts for transfers within the hospital. Maintains sudit sheets on all charts in such a way that information is kept up to dat on a daily basis.


Duties and Responsibilities; 1. Transcribes orders from the chart to the appropriate spot in the unit. 2. Makes up two completed charts daily so there are always charts available 3. Makes out any type
of requisitions necessary for suppliers, repairs, therapeutic feedings, transfers, etc. 4. Records vital signs on chart as indicated.
5. Compiles discharge charts as required,. 6, Makes out requisitions for medication requests and credit medications. 7. Takes medications back to pharmacy and picks up from pharmacy. Space Equipment and Materials Involved: Work Space in Secured Nurses Station and storage space for charts and medical forms and supplies. All clerical equipment on the unit plus all routine nursing procedure equipment as far as working conditions are concerned.
h. Program Secretary (admissions) Provides initial contact for pt, when arriving on the specified unit. Provides typing and filing services for the assigned units. Assists in the scheduling of staff meetings
and various family therapy sessions when directed to do so. Provides information and directions to patients, families, and visiting Drs.
May be required to perform some similar duties as listed above (g).
Space Equipment and Materials Involved: Private office open to admissions area with ajoining copy and storage room. Medical forms, desk, work table, files, typewriter, etc,
i. Director of Occupational Therapy The Director of Occupational Therapy shall be responsible for the direct supervision of Occupational Therapy services. The Director of Occupational Therapy shall be under the direct supervision of the Assistant Administrator for Clinical Services and shall have direct access to the Medical Director for supervision in clinical matters. Duties and Responsibilities: 1) Planning, development and implementation of Occupational Therapy services, 2) Preparation and review of the annual Occupational Therapy Budget. 3) Direct supervision of Occupational Therapy personnel. 4) Monitors the condition of Occupational Therapy equipment through a preventative maintenance program and takes corrective
68



/
measures as required. 5. Works with other hospital departments and administration to enhance communication and cooperation throughout the hospital. Directly supervises Occupational Therapy services.
Space Equipment and Materials Involved: Private Office near reg.
OT staff. Desk, chairs for 3 additional persons to meet, files and extra work table. Makes use of all OT materials and equipment.
j. Staff Occupational Therapist The Occupational Therapist participates as a memeber of a multi-disciplinary treatment team and integrates the principles and techniques of Occupational Therapy with the philosophical approach of their assigned unit. The Occupational Therapist evaluates the psychosocial, motor and affective aspects of a patient, formulates a treatment plan, and implements the plan, utilizing therapeutic tasks and approaches to facilitate an optimal functioning level for the patient. Duties and Responsibilities; 1. Planning and implementation of Occupational Therapy programs appropriate to the needs of the assigned patient population. 2. Implementation of appropriate patient evaluation procedures to determine the individual needs of the assigned patient pipulation. 3. Supervision of Occupational Therapy students. 4. Assistance with upkeep of Occupational Therapy equipment and work areas. 5. Coordination with all departments to enhance cooperation and communication throughout the hospital. Space Equipment and Materials Involved: Staff Office space with work station and filing space, and space for personal belongings. OT Clinic, childrens' classroom, woodshop. Makes use of all OT materials and equipment.
k. OT Clinic Coordinator Provides assistance to all OT staff with respects to their needs. This ranges from program implimentation, pt. supervision (if directod to do so) to equipment up-keep and cleaning.
To maintain adequate supply of materials for all in-use OT projects and search out the most economical means of purchase. C.C. shall assist in teaching the use of tools to staff and pts. if so directed and to assist TR staff in their equipment upkeep and purchases.
Space Equipment and Materials Involved: Staff Office with work station,
69


^7
r\
fa
woodshop, living skills room, childrens classroom, OT storage rooms, music room, Gym and other related ares. Shall be involved with all OT supplies and equipment and accepting deliveries of supplies.
1. Director of Therapeutic Recreation The Director of Therapeutic Recreation shall be responsible for the direct supervision of the Therapeutic Recreation Department. The Director of Therapeutic Recreation shall be under the direct supervision of the Assistant Administrator for Clinical Services and shall have direct access to the Medical Director for supervision in clinical matters. Duties and Responsibilities:
l. Program planning, exploration, and development which will expand the resources and facilities of the department. 2. Direct supervision of Therapeutic Recreation personnel, including Music Therapists; monitoring of the input by Therapeutic Recreation Specialists and Music Therapists in the medical record. 3. Cooperating in the teaching and research program of the Hospital. 4. Working with other Hospital departments and administration to enhance communication and cooperation throughtout the Hospital, and promoting the activities of the Therapeutic Recreation Department. Director directly supervises the Therapeutic Recreation Dept. Space Equipment and Materials Involved: Private Office near reg. TR staff. Desk, chairs for 3 additional persons to meet, files and extra work table. Makes use of all TR equipment and supplies.
m. Therapeutic Recreation Specialist Utilizes the skills, knowledge
and techniques of Therapeutic Recreation in planning and implementing a Therapeutic Recreation program in the areas of rehabilitation, leisure education, and recreation participation. Duties and Responsibilities : 1. Assessing patients in the Therapeutic Recreation setting
through the use of appropriate tests and observation tools. 2. Providing Therapeutic Recreation input in the medical record by writing progress notes, assessments, evaluations and reports, and by developing individualized treatment plans in conjunction with physicians and patients
as required. 3. Completing monthly inventory reports on equipment and
70


supplies; taking responsibility for the proper care and maintenance of department equipment and supplies. 4. Participating as required in providing Therapeutic Recreation inservice education on both a formal and informal basis. 5. Attending and contributing to patient care conferences, doctors conferences, team, unit and departmental meetings as required. 6. Taking responsibility for leading and directing Therapeutic Recreation activities, including those activities which require nursing staff assistance. Space Equipment and Materials Involved: Staff Office with work station, Gym, weight room, music
room, living skills room, equioment storage. Shall make use of all TR equipment and activity spaces.
n. Masters Psychiatric Social Worker The Master's Level Psychiatric Social Worker will use his/her clinical expertise to provide therapy to families of the hsopitalized patient and communicat pertinent information to the treatment teams and the attending physicians. The Social Worker will also use his/her knowledge of community systems to act as liaison/coordinator between the patient and outside agencies. Duties and Responsibilities: 1. Perform a Psychosocial Evaluation for each patient on caseload. 2. Maintain a direct liaison with families of patients, by providing information and support regarding hsopitaliza-tion to them. 3. Conduct individual, marital and/or family therapy for families of identified patients, in direct consultation/negotiation with the attending physicain. 4 Document in patient's chart all social work information pertinent to patient and family. 5. Attend patient's weekly Doctor conference to share information regarding treatment provided by Social Work Services, as schedule permits. 6. Maintain contact with necessary community agencies to coordinate their, assistance when necessary. 7. Participate in department meetings and supervisory sessions with department director. Space Equipment Materials Involved Private Office, Desk, chairs for 3 additional persons to meet, files and extra work table, and shelf space for books. Will deal with general office supplies and medical forms.
71


o. Director of Education Oversees all operations of the educational dept. This involves the coordination of academics offered and provided by inhouse teachers and those assigned to the hospital by various school districts (home-bound teachers). Position also involves active participation in the overall treatment philosophy of both children's and adolescent treatment units. The Director acts as the primary liason between all prominent educational agencies and acts as mediator when conflicts arise. The Director provides clinical input to Staff meetings and pt.-Dr. conferences. Space Equipment and Materials Involved: Private Office with access to staff teachers. Desk, chairs for 3 additional persons to meet, files, work table, side tables, shelves
for books,
p. Staff Teacher ST provides educational services to those patients who are in need of remedial and or "just keeping up with" assistance, as well as being a support for disrict teachers under the direction of the Director. Helps coordinate district teachers provided by the public school districts for the hospitalized patient. They shall assist the Director in administrative aspects of such coordination, including initial, ongoing and cumulative reports. Assist in providing inservice eduation regarding the psychoeducational modality and process for the total C.and A,Treatment Program. Writes weekly and ongoing status reports concerning psychoeducational program in patient's chart under Progress Note section, and on patient Treatment Plan. Space Equipment and Materials Involved: Staff Office with work station, near copy and supply room, space for personal belongings, files, shelves for Ed. books.
II. Molecular Activities
A. "Scenario of Admissions for Children and Adolescents",
-The child is invited to a short pre-visit day so that he or she may see the unit and talk with other kids about being there-Admission date is set-Child is brought willingly (or not in some cases) to an area to be processed (paper work wise). This is an important transition point due to the high anxiety level of the parent-child separation point.
72


From this point the child is moved to his room where he is placed with a child of the same sex and relatively similar development level unless support of another level is deemed appropriate. After the child is settled in, a physical exam is conducted and the child is then fully admitted to the unit.
Note: The difference between admissions of a child vs. adolescent
is that the adolescent may be more capable of handling the admissions situation at the hospitals general admissions area. If not, then a special place for admission should be provided as with the children's unit. There is also less likelihood of pre-visits with adolescents when compared with children.
B. "Scenario of the Days Activities".
Note: The Scenario of Day activities are similar on both units in
concept thus one example is given. The difference lies in the number and degree of activities and staff supervision. The children's unit will be more highly structured, with more activities to fill the time
slot. This is because at their developmental lavels many or most of the kids have not yet developed the needed internal controls and or
support systems to function in a less structured environment.
7 AM
7 to 7: 45 AM
7 :45 to 8: 15 AM
8: 30 AM
9 . AM to 11 AM
11 AM to 12 NOON
NOON to 12: 45 PM
1 to 2: 30 PM
2 :30 to 3 PM
3 PM
3 :30 to 4: 30 PM
4 :30 to 5 PM
5 to 5: 45 PM
6 to 6: 30 PM
6 :30 to 8 PM
8 to 9 PM
Wake up (day staff comes in)
Wash, dress and clean rooms Breakfast (on or off unit)
Community meeting to discuss issues for the day and taking of vital signs.
Various forms of school with possible intermixed private therapy sessions with Dr. or staff.
OT (off unit-some on unit) (childrens OT combined with ED. classroom).
LUNCH
Therapeutic Recreation Quiet time (rest & wind down)
Afternoon community meeting & taking of vital signs (evening staff comes in).
Additional study, play or OT time.
Clean up for dinner.
Dinner and clean up.
Quiet time.
Evening structured activity.
Small groups and wind down time. (for childrens units depending on child's age and behavior, bed time (getting ready) will commence).
73


9 to 9:30 PM Clean up unit and prepare to go to rooms.
9:30 to 10 PM Get ready for bed.
10 PM Lights Out.
10 to 11 PM Staff charting time.
11 to 11:30 Night staff comes in.
C. Unit Activities The following is a list of the most common activities carried on, On the Units and Off the Units. They are described here in terms of physical movement, type of space used, and common number of pts. involved in that space or activity.
1) Admissions Walking (possible wheelchair use), sitting;possible play with toys, physical transfer of papers and documents, writing. Open neutral space designed for pt. types. Rarely will more than one pt.
at a time be admitted=l child or adolescent, parents 2, receptionist 1, staff possible 2. Family visits in need of waiting could number 8 or 10 but would be uncommon.
2) Physical Exams Walking, sitting, stooping, jumping, lying, manipulating medical equipment. Clean standard medical exam and treatment room with considerations for age group dealt with. Not more than 2 staff and
1 pt.
3) Sleeping Lying (10-20% decrease in metabolic rate). Mental and physical regeneration. Space is usually a double or single bed room.
Never more than 2 persons per room.
4) Washing Self explanitory although some children may require assistance in this area. Space should be private with shower, toilet, sink and allow enough space for staff assistance. Max. persons 1 pt., 1 staff.
5) Dining Sitting, eating, conversing, relaxing, listening to low level soft music, viewing medium light source and warm colors. Max. space for 10.
6) Food Preparation Walking, bending over, reading, manipulating appliances, kneeling, opening cabinets and doors, seeing and smelling. Space
should allow an easy flow of movement when passing through or preparing food. Space should have proper light and ventilation to perform needed task. Max. in space could be 10.
7) Major Group Meetings Walking, mostly sitting, talking, viewing other patients, and staff (community meetings)0 Large unobstructed space
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with comfortable seating. Childrens unit 15 kids plus as many as 12 staff. Adolescent unit 20 kids plus as many as 12 staff.
8) Small Group Meetings -(Group Therapy Walking, standing, but mostly sitting, talking, viewing other patients and staff but in closer space but adventagious to be able to nestle in a more secure private space. Groups usually contain 1 or 2 staff and pts. numbering 4 to 8 max.
9) School Classes Concept formation and problem solving, sitting, reading, writing, typing, walking, listening to music, viewing, observing and operating computer display and other programmed educational devices. Space is typically classroom like as a school setting, with some low dimensional panels such as carrels. Proper lighting and good acoustics should prevail. Childrens classroom typically graduated from non-stimulating to common style. Individual group sizes 4 to 8, Max in space 20.
10) Occupational Therapy Stimulation of cognitive functions. Stimulation, development and refinement of fine motor abilities: grasping, holding, placing, turning, squeezing, lifting, touching, twisting,seeing, smelling. Operation of many tools, equipment and appliances. Individual group sizes 4 to 8. Max. in space 20.
11) Therapeutic Recreation Release of excess energy and emotions via, running, jumping, climbing and striking activities. Stimulating an enhanced level of fitness thru physical conditioning such as all forms of sports and weight lifting. Other areas involve the activity of relaxation thru reviewing and participating in theater experiences, listening and procuding music. Spaces are varied in size lighting and acoustics. Some of the activities are performed in controlled contained spaces and others in controlled open spaces. Persons involved may range from as small as 2 to as many as 50 or more for special occasions.
12) Individual Psychotherapy Involves sitting, standing, walking, talking, yelling, crying, reaxing, reviewing. Space is usually large enough to avoid the common sense of being closed in. Persons involved normally
do not exceed 1 pt. & 1 staff (Dr.).
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a
/
13) Play Therapy Similar to the above but makes the use of various toys and doll and other items used as therapeutic tools in treatment.
Space is nearly the same as above but without the office type environment and provides space for the child to move about freely. Persons
involved again don't exceed 1 pt. and 1 staff (Dr.).
14) Family Therapy Molecular Activities here are similar to #12 above but involves group dynamics instead. Space is usually larger than
a regular office. This is because therapy sessions may involve a number of families together who do not know each other thus requiring greater physical distance for personal emotional comfort. Persons involved may be 1 or 2 therapistis plus family or families (parents) number of individuals 8 max. efficiency.
15) Group Recreation Here activities are more restrained when compared with regular TR. Such that they are performed indoors: Seeing, hearing, manipulating cards and game pieces (board games), sitting, talking, walking, mental and physical interaction and confrontation plus eye
and hand coordination games. Space is indoors, contained and well lighted. Groups involved can range from 4 common to as many as 20 max. for safety and control factors.
16) Dispensing of Medications Involves unlocking and opening cabinet doors to acquire medicines, writing down the dispensing of such, washing hands, walking. Space involves a contained security area accessable only to staff with locked housings accessed only by med. nurse. Persons involved one person only except when med. counts are performed then the number is 2.
17) Documentation of Patients Progress and Behavior by Staff and Drsa -This involves sitting, writing progress notes in pts. chart and sometimes involves conversing with said pt. during this process.
Also involves having controlled access to pt. charts. Space used can range from on unit, staff station or nurses station. Some Drs. may prefer to do this in a private office or dictate the data in the medical records space. Number of persons charting at one time may involve 10.
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18) Patient Chart Upkeep This activity is performed by the Unit secretary and involves manipulation of charts and materials in
the nursing station. Involves sitting, standing, verbal communication with staff, pts., and Drs. Space is usually contained and secured for pt. confidentiality with flat work space and accessable to normal staff.
19) Patient-Doctor Conferences Involves walking to area, sitting, talking, listening, seeing, writing. Space should be pricate and large enough for all staff concerned plus pt. Total number of persons involved including pt. does not normally exceed 7.
20) Department Staff Meeting or Inserviees Involves similar molecular activities as above with the exception of occasional film and slide presentations. Space is usually large enough to accomodate staff with seating and writing surface. Number of persons involved can range from an average of 8 to as many as 16 or 20.
21) Morning, Afternoon and Night Shift Reports Involves sitting, walking, standing, talking, listening, writing, interacting with patients.
Space involved, most anywhere in the unit. Morning and Night Shift Reports are usually conducted around the nursing station. Afternoon Reports are usually conducted with patient participation in a large open dayroom area. Number of persons involved including staff can range from 7 to 27
22) Patient Phoning Home (E.T.) The title explains itself. The space involved should be semi-private but open to staff observation.
Persons involved, usually one, but two phone stations may be required.
D. Average Staffing of Units (except weekends)
Childrens Unit (15 beds) Adolescent Unit (20 beds ) X2
Days: 1 Charge RN
1 Charge RN
2 M.H.W.
1 Program Secretary 1 Unit Secretary 1 Unit Director
Days: 2 Charge RN 4 Staff RN
4 MH.W. (6 if needed)
1 Program Secretary
2 Unit Secretary 2 Unit Director
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Average Staffing of Units Con't
Childrens Unit (15 beds)
Days: 1 Unit Consultant
1 OT Staff 1 TR Staff
1 Social Worker
2 Teachers + 1 Spec. Ed.
Evenings: 1 Charge RN
1 Staff RN
2 M.H.W.
Nights: 1 Charge RN
1 M.H.W.
(possibly 2 if needed)
Adolescent Unit (20 beds) X2
Days: 1 Unit Consultant
2 OT Staff 2 TR Staff 2 Social Worker 8 Teachers + 1 Spec. Ed.
Evenings: 2 Charge RN
4 Staff RN 4 M.H.W.
Nights: 2 Charge RN
2 M.H.W.
(its suggested that this # be increased to 4 due to safety of staff)
III. Specific Facts
(Derived from analytical reserach and scientific studies) as they relate to the psychological needs in the treatment environment. The following list of facts relate to both type of treatment units. This list shall be followed by facts that relate to problems with present facilities followed by facts related to color, light, and last the "childs need for play".
A. Admissions is an important transition to therapy and is seen as a neutral space.
1) Most pts. will be comming from a middle, upper middle and high social class structure. Kids to be treated fall into many categories yet the common denominator is that most are fragmented in their thoughts, lives and experiences to some degree. This translates into a need for identifiable and well oriented spaces. Patient envolvement should emulate the family setting as close as possible such as: kitchen, dining, living room type spaces.
2) Dining is occasionally prepared and provided for on the unit with most meals eaten off unit in the hospitals cafeteria.
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=vI7
rv
3) Drs. and staff should feel that there should be no place on the unit that is out of sight and out of mind. Such spaces increase anxiety and disorganization.
4) Children and adolescents are at times loud, noisy, and very disruptive to other hospital activities.
5) Children and adolescents at times, are highly destructive as they often act out their emotions on inanimate objects (such as doors, walls, furniture).
6) Patient privacy is very important and should be provided for.
7) Safety of patient and staff is always of primary concern.
8) Staff charting shall not be performed in private making staff in-accessable to patients.
9) Good visual contact and access of staff must be mainained at all times, not only for the kids well being but for staff too and ward management.
10) Medication requires a separate dispensing space of high security.
11) Due to occasional and sometimes frequent violent and self destructive behavior, pt0 seclusion room need provided for. This is a space where a pt. can be neutralized, behavior wise. The space may not contain any items that can injure the pt. or staff and provide for easy observation of pts. behavior. Must meet code. This space shall not remove all stimuli nor should it remind the pt. of a jail cell. This is because many adolescents have spent time in such an environment.
Patient dignity must be maintained.
12) Bathroom facilities should be located close to seclusion rooms for those pts. needs and that additional sense of caring.
13) The patients room with finishes and furnishings shall instill a sense
of pride about his or her environment yet be durable enough to withstand a high degree of physical abuse.
14) Patients need to have access to personal lighting (task) in their rooms so as to create a normal environment for study, reading or writing without disturbing his or her roommate by using the ceiling light.
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15) Adolescent patients should be afforded the privacy and dignity of a private bathroom contrary to what's provided in some facilities.
16) Patients shall be provided with a high quality non-breakable mirror so that they may evaluate personal grooming skills and judge their body image.
17) Children need not have a private bath in their room because: 1) This would not be a normal home situation 2) many younger children need assistance with the performance of various bodily functions. This can dealt with (monitored) better by common bath facilities that are still seperated by sex.
18) Except for seclusion, nursing station and specific storage spaces and on unit access-fire dors, locks should not be present especially on pt. doors. If used they simply set up a condition of mistrust towards the staff. Some facilities still lock all the rooms when the patient is not there.
19) Thru experience, psychiatric hospitals have discovered that care should be taken in the choice of furnishings and fixtures because of the pts. ability or probability of transforming such into a weapon to injure self, staff or others.
20) Experience and time has shown that private psychotherapy should be conducted off the pts. unit. This is important to therepy because of the psychodynamics of a separate, safe, place to talk away from the unit and the ears of unit staff. When pts. are seen by their Drs. on the unit they often feel that if they say some things to their Dr. about how they feel or what they have done, that staff will immediately hear of it and they might be punished thru loss of privilages.
21) It is also felt that family therapy and administrative functions should be conducted off the unit to avoid interruption of unit activities
and tratment continuity.
22) OT activities will involve living skills, woodworking, goal oriented craft activities, sensory intergration and evaluation, testing, and exposure to new experiences.
23) Indoor and outdoor activity (play) areas are required that are large enough for 20 to 40 and unobstructed.
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Facts That Relate to Problems with Present Facilities ,
Unit Orentatlon and Finishes
The problem with most facility living spaces is that they either look like a hospital word (long, dull, sterile hallways) or look like a special cottage set up with poor staff supervision (functional orientation) and blind spots.
Present spatial images of psychiatric units isolate pts. activities and living quarters and lack the focus of "home & family". Although "Mon & Dad" (staff) are primary as central focus with children, adolescents wish to feel that they are a bit more grown up. This requires the development of a psychological sense of distance from staff.
Many of the finishes-materials used, are either hard and harsh or unable to withstand abuse. A common material found in use for walls is painted cinder blocks or actual exposed concrete walls. The staff in those facilities admit that they dont like such an environment for the pts. nor themselves.
Some facilities have dealt with the harshness of walls by using drywall, but the cost of repairing holes caused by kicking or hitting has caused them to use "Kydex". This is an extremely tough non-breakable plastic that comes in sheets and in a variety of colors and can be painted. The use of this material has eliminated the "hole" problem, but is very expensive when all hallways and pt rooms are lined with the material. There are some concerns expressed in this area with regards to the possible toxic fumes emitted during a fire, especially when used so extensively in a facility.
Lighting
Lighting is another area of concern in psychiatric facilities.
Common remarks are : "It's too bright", Its too dark", "No task lights in pto rooms-but you can't have lamps because pts. will throw them at you or use the outlet to kill themselves", "Patients just can't see well in their rooms", "Staff can't control the lighting levels, especially in hallways at night and this causes problems with a lot of kids. When the light is the halls near their doors go out
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a
To
for the night, many become frightened", "Staff cant properly decrease lighting levels to correspond with the level of enveing activities and "wind-down" for bed.
Storage and Furnishings
Most facilities state a lack of storage space for pts. belongings. "They dont have enough space to store (put-up) their clothes, or for books, knick-knacks, or other personal belongings". Staff and pts. also complain that most furnishings are too sterile and instititional. The problem is more pronounced in children and adolescents. This is because they accumulate a lot of items (toys, OT projects, etc.) over their long periods of treatment.
Another common problem found is the issue of "Drapes". Most systems used by facilities for drapes get torn down and ripped up primarily due to the ynaking and jerking motions used to open them or thru acts of pt. violence. Pull cord systems have been eliminated over the years because of the possible act of a pt. hanging themselves.
Hook or snap-pull type systems are presently in use for the lack of better systems but they still get torn where theyre attached.
Some facilities have chosen to use solid metal bars with velcro loops provided to hold up the drapes. This has been criticized by some because a pt. could use his bed sheets to hang himself from the bar. Other hospitals have chosen to glue long strips of velcro above the the windows and sewn the same to the drapes. Unfortunately here its an "All bn" or nothing deal (could hang half off) and is a visual eye sore.
Colors
Other problems pointed out by many staff and patients is the arbitrary use or lack of use of color. Many facilities have experienced the frustration of poorly chosen colors, deep bright or dull solid colors use throughout, father than for accenting areas. Often they respond with the "cop-out" color white (or off-white) everywhere.
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Windows
Windows continue to present a problem in all psychiaric facilities., There is always the concern for the patients' safety if he or she decides to escape thru a window in their room. Some Architects and Designers have chosen to reduce the number and size of the windows and have replaces all the galss with one of a number of special plastics. This has reduced the glass breakage (cuts) and elopement risk but has increased the pts. isolation from the outside world.
Some of the plastic panels have been known to be popped out due to the manner in which they are secured and the aggressiveness of the patient. Some patients have even tried to burn their way out using lit aerosol cans as a miniture blow tourch. Facilities that have had plastic window units designed to resolve the popping problem, still have to deal with the pts. scratching or carving lines, words or initials in them.
These types of problems have occurred in every facility surveyed that has used the plastics. Over a short period of time visual access to the outside is severly inpaired, not to mention the messy apperance and lack of self worth projected by the esistance of such windows.
Even if the plastics are not used in pt. rooms, just general cleaning over time will severly decrease its clearity. The problems with window design are a good argument for placing children and adolescents on the ground level, since they have the highest elopment risk. Acoustics
As observed in all facilities visited, and commented on by staff, is the problem of acoustics. Common problems that exist are as follows 1) Acoustical privacy is lacking in private therapy offices (rooms) which inhibit pt. progress. If the pt. can hear people talking next door or out in the hall, then the pt. feels that the reverse is also present. Thus the pt. will be less likely to discuss issues as freely as they could or would. In addition, during occasional outbursts of "transferential behavior" a pt. yelling at his therapist can be



/
quite disruptive to other activities, 2) acoustical control is lacking in the area of seclusion rooms. At times a pt. in seclusion will resort to continual yelling or banging on walls. This is considered quite disruptive to the rest of the unit. Some facilities have tried to address this problem by lining the S room with carpet but leaving the walls outside the room hard and reflective thus the problem still exists to a degree,, By lining the room with carpet, they had created another problem, that of keeping the room sanitary. Pts. are known to urinate plus perform other such acts on the walls, Some facilities don't bother with carpet or anything, they have simply tiled the floors-waterproofed the walls and places a chair in the floor so it can be hosed down like a zoo cage.
Some facilities have tried to deal with the noise level be placing the room far away from staff and pts. even to the point of moving them to a special building that houses many seclusion type rooms.
By doing this they have created another problem. This magnifies the pts. feelings of isolation (I'm not wanted and staff doesn't care) plus it separates and singles out that pt. as being more sick and can set up a condition of fear and redicule among the pts'. peer group. 3) Another acoustic problem lies in the area of main circulation, gyms and OT clinic spaces,, High reflective surfaces plus high noise levels can greatly increase a patients' already high anxiety level making some areas frightening and unusable to them.
B. Facts Regarding the Physical and Emotional Effects of Color and Light Colors in General
The colors that may be used in a psychiatric facility along with white are defined as the psycholofical primaries; red, yellow and blue. These are the udes that people most readily identify and desire. The color red has been stated as having the ability to promote creativity, strength and confidence. It can evoke passion or aggressive actions from prople depending upon the saturation level chosen. The color red also has the capacity to increase an individuals blood pressure. Yellow is often associated with warmth and compassion and
84


security. It also has the capacity to increase the matabolic rate of various individuals. Blue was the last color chosen. The color blue is most often associated with that of a sense of belonging or that of depression. It has the capacity to lower the blood pressure, decrease resperation and in general will relax an individual.
Color with Respect to Children and Adolescents
Both statistical analyses and case studies indicate that children's use of color, line, form and space give distinctive insights into personality development. Color has been found to give the clearest insights into the childs* emotional life. Children who emphasize color tend to have strong emotional orientation. Specific color preferences and specific patterns of color placement five clues to the emotional make up of the child and with adolescents a possible developmental level never resolved or.regressed to. Data supports the view that red is the most emotionally toned of all the colors. From a developmental standpoint, red is a preferred color during the early preschool years, when children are naturally functioning on an impulsive level. Interest in red decreases and interest in the coolere colors increases as a child outgrows the impulsive stage and moves onto a stage of reasoning and greater emotional control
Some studies have shown patients to prefer warm masses (red-yellow-orange) during emotionally disturbed periods., A preference towards forms and lines in cooler colors have been found to parallel periods of happy adjustment and of constructive relationships. As mentioned earlier, emphasis on red has been to be associated with either of two extremes: a) feelings of affection and love; b) feelings of aggression and hate.
As determined from observation and studies, where pt. drawings or choide of colors used in other projects were examined, a direct relationship between emotional state and color choice have been noted.
In one study it was found that only red oriented paintings were done by a rejected, neglected child who usually painted in somber colors in keeping with her predominantly dejected feelings. While emphasis
85


emphasis on red seems related to strong emotional drives, emphasis on blue seems more often associated with drives toward control.
Children frequently select blue as they turn away from masses and begin to work with more effot towards control in line and form.
It's been observed that many children who come from particularly high-standard homes, homes geared to adults rather than children, will turn to blue after an absence from school when they have been home, and gradually work away from blue as they again adjust to school and begin to function more freely and at the more impulsive level natural for children of their age group. Generalized trends have also been suggested by a child's use of other colors0 Green, like blue, tends to be use by children who are functioning on a relatively controlled level and show few unusually strong emotional reactions.
Other facts recognized show that children have some difficulty in distinguishing between the light and dark shades of color and often interchange them. It also has been observed that children tend to choose preferred colors more often than the non-preferred colores; thus, blue, red & green are preferred to orange, yellow, and violet chosen more often by adolescents and adults.
Lighting
The design of a lighting system should provide for the individuals ability to see and perform specific activity or task. Light is a variable factor and changes in color, direction and diffusion affect the subjective impression of the environment. Whether emitted by a natural or artificial source changes in the concentration of or characteristics, light emission often induce subconscious responses in people. Therefore the fundamental relationship between light and "seeing" is not only a factor in visibility, but can be a controllable element of emotional consequence.
Psychological reaction can be achieved through a change in illumination. High intensity illumination contributes to a sense of increased activity


and efficiency. Low intensity lighting tends to create an attitude of relaxation or depression. These two aspects with respect to degree can be controlled by a dimmer. The distribution of brightness can affect the emotional response to an interior space also. Lighting can either emphasize or subordinate various aspects of the environment or activity.
A high level of horizontal illumination causes the people and activities in the space to become the dominant features with the structure beaing secondary in nature. This causes an increase in over consciousness of movement and people, and generally encourages a more gregarious attitude among the occupants. On the other hand, a shift to vertical illumination in general induces a more introspective attitude, and intimate atmosphere with a feeling of privacy.
Studies have shown that light fixtures used in psychiatric facilities should produce no glare as it can be quite disturbing to many due to their emotional state and type of medication they may be on. Other studies have shown that lighting systems in most cases should not produce shadows. This is because shadows tend to distort facial characteristics which can cause pts. to misinterpret facial jesters (emotions and possibly create adverse situations. Also shadows can cause a pt. to be afraid of certain areas at night.
No dark zones should exist on the psychiatric unit for safety reasons. Lighting of doorways and communication areas are of prime concern. Florescent lamps should not be used in areas where high-speed rotating or spinning equipment is used. This is because of the strobelight effect they produce and the possible cause of injury to its operator (pt.).
D. Play and Movement in the Education of Children
For children, play is at the very center of their lives. The play world of children is the primary means by which they learn about themselves and their environment. Play and work are not opposites as is often thought by afults. For children, play is their way of exploring and experimenting while they gain important information about their ever expanding world. The activities of many children are literally a
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primary means of education. The environment that is planned for children indoors as well as outdoors, plays an important role in determining the quality and quantity of this education.
The treatment environment must be one that is conducive to enhancing all aspects of the child's development,, It must stimulate the development of his or her physical abilities in all areas of movement. It must be conducive to enhancing and reinforcing fundamental cognitive concepts. It must also promote acceptable forms of social and emotional growth. All of this help develop a healthy well adjusted child and for that matter, adolescent.
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'vy

CHILDRENS 15-BED unit
*of units FUNCTION- ORIGINAL PROPOSAL PRESENT PROPOSAL
owut NtV UNIT NS.F UN IT N.5.F
b 2 4 Bath Room I 70 340 80 320
3 3 i BCD Room I oo 300 IOO 30 0
D O security Room I oc 200 IOO 200
i i NURSINE STATION 250 250 200 ZOO
o i STAFF STATION -o - - o - so 80 .
1 1 M£D, Room 5fc> 5 l 1 Clinical SUPPLY 40 40 40 40
1 1 Clean linen 3o 30 30 30
| 1 SOIlED Lin FIN 70 70 70 7 O
1 1 JANITOR 3o 30 AO 40
1 1 FT NOURISHMENT Coining) 80 60 200 zoo
1 1 PT. SToRA&e 30 30 40 40
o 1 UNIT' Tor STORAGE - o- -o - 1 OO 1 oo
1 1 day. Room 9oo 9oo 600 bOO
1 1 ACTIVITY ROOM - o - - o - 600 (a O'Cj
1 1 LAUNDRY -o- -o - 80 RO
o 1 BED Room transition SPACE -o- -o- 250 £50
1 1 STAFF loUn&E I oo 1 oo 1 50 1 50
1 i STAFF ToilcT 25 25 40 4 O
3 1 TREATMENT (Exam) l 20 3 CO 1 5 O 1 5 C
O 1 IMTERviEW-staff comF. eoom -o - -o - 1 30 1 30
2 1 i mterviEw (seboiAeji I 20 2 40 1 iO 1 i 0
I 1 Ul'iiT uiPECTcR 80 80 1 i 0 i i C
I 1 UN |T consultant 80 RO 1 10 1 10
1 1 Social SERVICES I 2 O 1 20 1 10 1 10
\ 1 Parent croup meeting I 44 1 44 1 50 150
O 1 TESTING w/OBS£EvaTicN ROOM - o - - o - 200 ZOO
o 1 ADMISSIONS AREA - o - -o - 200 200
o I PROGRAM SECRETARY -o- - o - 1 1 O 1 l 0
o 1 FILE & SUPPLY STORAGE -o - - o - 80 RO
o 2 ToilET -o - - o - 54 108
1 O &YTRA OFFICE 80 80 - o - -c -
1 o teachers WORK I 20 1 20 - o - - C -
1 o class room 700 700 - o -o -
AQOvIE TOTAL (s, 3 AftOV/u total (5.'T6^
Total 5, 5l5 '<*3 -fe. 744W FT 7 ITT A L 4 Tfi-1 < l.t <4,5 74 4)
E-fACTO e_) FACTO c.
A) r.iiA*o i oi f'L ' 8 744 ^ ) Cufi-H 0 TO TAL-- 9. 5 74 4-







89


ADOLESCENTS 20-BED UNIT x 2
UNfT5 FUNCTION- ORIGINAL PROPOSAL PRESENT PROPOSAL
c*< to. NEV UNIT I4S.P UNIT N.5.F
3 2-Red Room w/rath 244 a r3c 25 7.5 2 317. 5
£ £ 1 BED Room w/Bath &_-/ ) 1 7 4 34 I 7 7. 5 355
1 I NURSING STM'I ON 3 GO 3 GO aso 250
O 1 5TAFF StATlCM -o- -o- eo 60
1 1 M £D "Roor-i eo 80 eo 6 0
1 1 Clinical SUPPLY 40 40 45 4 5
Cuban linen 30 3o 35 35
l SOilIsO lin£n 70 70 75 75
i 1 u AN i T OPn 30 30 35 35
i 1 TT. NOURl jHMENTTWNntt.) 1 o c 1 DO 1 20 120
i 1 PI'. LTcRAet 40 40 45 45
0 I 6AM£ STORAGE - c- - o - 45 45
i 1 LayRoom 500 5oO (oOO (pOCj
1 1 ACTIVITY ROOM 70 C 700 loo 700
1 1 LUANPKY So So SO 90
o 1 BED Boom TRaNSiT ion SPACE -o - - o- 300 300
1 1 handicapped sath e 80 eo 8o 80
a a security room loo ICO 1 o o 200
i i security BATr 5 ip 5 O 7 0 70
si* (5 hared FUnlt icNS^ ABovg/roTAio (4, 980) *2=(9,9bCi ABOV£ TcOAli (5.4525 X 2= IC.9C5
i 1 STAFF lounge i oe 1 (ofc lu>0 Its
1 1 STaRF ToilET 3S 2 5 47 47
i 1 TREATMENT (EXAM.") 1 (c ft 1 U 6 l 44 1 44
fo 4 INTE-Rvi&w ROOM i i o i i 0 440
a £ Unit Director cou.e) 1 oo 2.00 1 IC 220
2 SOCIAL S£RVlC£SCCfFit£i 1 i o 2 20 1 1 0 i i 0
o 1 LARGE PARENT GROUP M FETinG -o- -o- 1 BO 1 BO
o l small Parent group mfftiN6 - o- - O- 120 1 20
o 1 UNIT CONSULTANT - o - - o - 1 IO 1 l O
o 1 TESTING ROOM - o -o- ho IlC
1 I PROGRAM SEC- vu/ COPT ROOM 1 7 Co 1 7L 230 230
o I ADM 1 SSlONS/vvAIT r (SJ & - o - - O- 1 20 1 20
o a PUBuL Toilet - o - - O - 54 lOS
1 i STAFF GROUP MGFTiNG 204 20 4 204 204
O.eei) + 9,9 SO) (2,451) + >0.905)
Toiai. =0 >. &4 ifc I.GS = \9 b5fc so.n rcTA^Oa, 27b)x l.fc: *2l,24l.b
(fA,oe)
A3 G>f2>KM & TCTAU 'iS.fcSfcB) £R>*HO T\XAi_: :2l,2Al.b








90


n.
/
THERAPEUTIC-SERVICES-CENTER
*of UNITS FUNCTION ORIGINAL PROPOSAL PRESENT PROPOSAL
OW. NEW UNIT N5.f= UN IT N.5.F
OCCUPATIONAL therapy
i i o.T. Director 1 2C 120 1 20 1 2o
1 i O.T. STAFF OPFfCF 0* P?*sofn) 24C 240 3 GO 3GC
1 i O.T, CL 1 NIC 700 700 1 ooo 1 ooo
1 i O.T wooDSHOP 7 GO 7GO 8So esc
C l O.T GREENHOUSE - c -o - 22 s 2 25
t i living skills 'Room 9 GO 9go 9 GO 9CC.
1 i OT STLRA&6 2 GC 2GO 2 75 275
o l sensory intE6ration tza - o - - o - o- - o-
THE RARE UTlC RECREATION
1 i -T, R T>lRECTOR 1 20 120 1 2.0 120
1 i T R. STAFF OFFICE Ciumuvtii) 44o 440 3 (rO 3 c*
c i T.K EQUIP- STORAGE -o- - o- 3 lO 3 i C
o i AUDIO VISUAL STDRA6E - o- -o- 1 44 1 44
o i MUSIC THERAPY -o - o- 3oo 3oo
c l WEIGHT TRAINING S3^ei-)oi -o - -o- loo 3oo
o i Gym - o- - o- 0, OoO G, ooo
c 1 AUY. STOEAGE - o - - o- 1 30 i 30
c 1 STAGE -o - - o- Q,oo G OO

1 i Director op education 1 20 1 20 120 I 20
1 l STAFF VI SITING T£ACHI?fcS6s 240 240 3 Go 300
c l Consulting opficp - o - -o- 1 20 1 2 0
1 l CLASSROOM CchiLOR.ITN ) 700 700 7 OO 7oo
1 i C LAGS ISooM (adolescent ) 700 700 7 00 700
1 l C L ASS PC O M c u PJCAR.Y -COMPutEE) 3oo 300 400 4co
c i COPY/.SCHOOL SUPPLIES i.£OUiP, -o- - o- 1 50 1 so
COMMON SPACE
c i WAITING SPACE fJEATINt,-) -o -o 450 4 SO
a £ PUBLIC ToilET -o- - o- 54 1 OR
c 1 JANITOR. -o - - O- 45 45
'F SECURED OUTDOOR ACTIVITY SP/&CE- p 5, G6C*. l,2K(/-) 7.344 ^bTAA. ABDV£ -15.207 K I.JTC-J: |S,00
f^iurr i NCLunen in total so ft! Bel)
1 1 | JsLARGE OOTOcoR SPACE (aogl .) 5,Gc?o 5. GOO 5,000 5. ooo
i ( £MED. oJt door space Ccuiuxeti) 3.000 3, ooo 9. Goo 2.^00
Total= > 8. Goo TOTAL. = 7 GTiO


CP ACE PUlLED FROM EXTEA qflJCE
list ReauiPeD fou tesifeN op-
General admission s £, peep. * CHoT PA8T c f MA^uC. F ii}fc>f2A.Cr\ t>OC O MI £n T r C?
ri 1 ClETSHOP 3^0 39 G
-*! 1 ADMITTING R.ECP. l 20 120
\\ 1 PT. REP 24-0 24 D
a' | LOBBY 528 528
*i 1 PUBLIC toilet | 20 2-40
Tctal - > 1, 159 Y 1. 4 Z (PATlUl ^ = 1, G44. 3t SQ.FT.
91


ADMINISTRATIVE SERVICES
NO. FUNCTION UNIT NSF
1 ADMINISTRATOR 288 288
1 MEDICAL DIRECTOR 288 288
1 SECTY/WAIT 288 288
1 CLOSET 20 20
1 STORAGE 20 20
1 PATIENT ACCOUNTING 360 360
1 DIR. PATIENT ACCOUNTING 110 110
1 BUSINESS 640 640
1 DIR. FISCAL SERVICES 110 110
1 CONFERENCE 350 350
3 TOILET 25 75
1 JANITOR 25 25
1 MEDICAL STAFF 288 288
1 MEDICAL RECORDS 500 500
1 DIR. MED. RECORDS 120 120
i DICTATION 100 100
* 1 RECEPTION 120 120
*i PATIENT REP 100 100
LOBBY 528 528
*i ADMITTING O (XI 240
*2 PUBLIC TOILET 120 240
*1 JANITOR 30 30
1 NURSING SUPERV 120 120
1 UP. ORIENTATION/CONF 240 240
1 SECTY/WAIT 640 640
5 ASSISTANT ADMINISTRATOR 120 600
1 - MAIL/OUPLIC 100 100
2 STORAGE 50 100
1 EMPLOYEE RELATIONS 270 270
1 PROGRAM P&D 270 270
7,180
FACTOR
1.42
DGSF
HOT


AHCILLARY AND SUPPORTIVE SERVICES
NO. FUNCTION UNIT NSF
1 DIETARY 4400 4400
c OFFICES 120 240
1 JANITOR 30 30
1 SOILED LINEN 150 150
1 HOUSEKEEPING 680 680
1 LINEN 800 800
1 PURCH/STORES 2240 2240
1 MAINTENANCE 1000 1000
1 BOILER ROOM 1440 1440
1 CHILLER ROOM 525 525
1 ELECT ROOM 250 250
1 TELEPHONE 80 80
1 MALE LOCKER/LOUNGE 430 430
1 FEMALE LOCKER/LOUNGE 550 550
2 TOILET 144 288
1 GIFT SHOP 396 396
1 CHAPEL 250 250
1 MEETING ROOM 950 925
1 PHARMACY 790 790
1 OFFICE 120 120
1 STORAGE 120 120
1 CONFERENCE 168 168
T5T577
FACTOR
1.11
DGSF
17,600
93


ADULT UNITS
CLOSED UNIT 25 BED:
no. FUNCTION UNIT NSF
12 2 BED ROOM 190 2280
l 1 BED ROOM 120 120
13 BATH 49 637
25 CLOSET 5 125
1 NURSING STATION 360 360
1 MEDICINE 80 80
1 CLINICAL SUPPLY 40 80
1 CLEAN LINEN 30 30
1 SOILED LINEN 70 70
1 JANITOR 30 30
1 NOURISHMENT 100 100
1 STORAGE 40 40
1 OFFICE 100 100
1 OAY ROOM 560 560
1 ACTIVITY 700 1 700
1 LAUNDRY 90 90
1 HANDICAPPED BATH 80 80
OPEN UNIT 17 BEOS:
8 2 BED ROOM 190 1520
1 1 BED ROOM 120 120
9 BATH 49 441
17 CLOSET 5 85
1 NURSING STATION 300 300
1 MEDICINE 80 80
1 CLINICAL SUPPLY 40 80
1 CLEAN LINEN 30 30
1 SOILEO LINEN 70 70
1 JANITOR 30 30
1 NOURISHMENT 100 100
1 STORAGE 40 40
1 OFFICE 100 100
1 DAY ROOM 450 450
1 ACTIVITY 470 470
1 LAUNDRY 90 90
1 HANDICAPPED BATH 80 80
4 SECURITY 100 400
2 BATH 56 112
3 SOCIAL SERVICE 110 330
4 INTERVIEW 110 440
1 GROUP MEETING 264 264
1 TREATMENT 168 168
1 STAFF 168 168
2 TOILET 25 50
1 SECRETARY/WAIT 176 176
2 OFFICE 110 220
TOTAL 42 ADULT n,8'96
FACTOR
1.68
DGSF

94


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/
GERIATRICS ANO PSYCH MED UNITS TWO 14 BED UNITS:
NO. FUNCTION UNIT NSF
12 2 BED ROOM 190 2280
4 1 BED ROOM 120 480
16 BATH 49 784
16 CLOSET 5 80
2 NURSING STATION 200 400
2 MEDICINE 80 160
2 CLINICAL SUPPLY 40 80
2 CLEAN LINEN 30 60
2 SOILED LINEN 70 140
2 JANITOR 30 60
2 NOURISHMENT 80 160
2 STORAGE 40 80
2 OFFICE 100 200
2 DAY ROOM 720 1440
1 ACTIVITY 525 525
2 HANDICAPPED BATH 80 160
2 TREATMENT 120 240
2 SOCIAL SERVICE 110 220
4 INTERVIEW 110 440
1 STAFF 160 160
1 TOILET 25 25
1 LAUNDRY 90 90

FACTOR DGSF
1.63 13,500
95


CONCEPTS

r\
7a
1) Written Concepts that Apply to Facility Design
The building should take on a low visual profile architecturally, two stories maximum in height, and possibly present itself in a campus attitude so as to blend into the community environment.
The building should be broken up yet kept cohesive to maintain an internal circulation yet separate the pt. housing and activity areas from other functional spaces.
Hospital circulation should be more than just that, it should provide variety yet well oriented in direction to activities, and provide central meeting points for those activities. Circulation should provide places to sit and rest, to think and contemplate one's feelings.
Consideration should be taken to account for the stacking of the hospitals other treatment units, as shown in the extra space list.
The children's and adolescent treatment units should be positioned on the ground level as suggested by Joint Commission an obvious safety reason due to eleopement precautions common with those age groups.
One should also be concerned with those other units having easy access to the Therapeutic Services Center and other pt. oriented functions.
One should be concerned with the ease of access to these units from the hospital's general admissions area.
The general admissions area should contain the functional spaces found on the extra space list provided earlier.
The general admissions area should be central and accessible by all units and to those entering the facility
The admissions area should be open and inviting via color, texture and lighting so as not to over stimulate or emotionally suppress the pt. during his or her first exposure to the facility.
Admissions for childrens unit should be completely separate from general admissions, but the adolescent units may have an admissions area accessible from main circulation.
Admissions should be on or near treatment unit.
Admission space should provide a neutral environment
96



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/
Support faculities should be grouped together such as administration, admissions, treatment and therapy rooms. These functions should be separate from the primary treatment units bpt in close proximity for ease of access.
All activities except OR, TR, Ed. & Outside recreation should be contained within the units structure.
Nursing station should be the primary focal point for pt. care, especially with childrens unit but with less emphasis on the adolescent. units.
No living unit or activity area should be isolated physically or psychologically from the primary treatment agents.
All activities should revolve around primary focal point.
Nursing station should not set up a staff pt. barrier.
Seclusion rooms should be in immediate proximity of staff for observation & care. A patient bath should be near seclusion rooms.
Seclusion rooms must reduce external stimuli for pts. well being but not be devoid of human dignity, plus acoustical control of sounds should be dealt with.
OT space should be provided for off unit (primary) & on unit (secondary).
Dining space should be provided for on unit.
The patient's room should have finishes and furnishings so as to instill a sense of pride about his or her environment, but of types less likely to be used as weapons.
The patients should have access to personal (task) lighting in their rooms so they may read, write or perform other tasks without having to use the ceiling light.
Bath facilities shall be combined to provide a home type environment yet segregated according to sex for children, where adolescent pts. shall have private baths.
Ample bulletin board space should be provided for display of pt. shaceules, goals & activities.
Patient should have easy access to protect outdoor activities, OT, Education, TR, and Living Skills spaces.
97