Behavioral health care is a broad term including mental health, lifestyle, substance use, and more. Facilities specializing in this care promote mental well-being by preventing or intervening in mental health issues such as depression and anxiety, and alcohol and drug addictions.

Plumbing engineers face unique challenges when working on behavioral health facility projects. These specialized environments require a deep understanding of safety protocols, design philosophies and patient needs. This article will provide insights for working on and in behavioral health facilities, and explore safety risks, budget constraints, patient populations, regulatory challenges and emerging design trends. 

What You Need to Know About Safety

Safety is the No. 1 priority for behavioral health facilities — for patients, staff and visitors alike. When designing and specifying plumbing products for behavioral health facilities with patient safety in mind, one crucial concept to note is “ligature resistance.” 

A ligature point refers to any feature that could support a cord, rope or other material for the purpose of hanging or strangulation. Statistics show that a significant portion of self-harm incidents in behavioral health facilities occur in bathrooms and showers, notes The Joint Commission Journal on Quality and Patient Safety (https://bit.ly/4dZak4Q). As such, plumbing engineers must approach every aspect of their work — from fixture selection to pipe placement — with an acute awareness of potential risks.

Figure 1 indicates the dangerous ligature points in a hospital restroom with an orange arrow. These include sinks, toilets, showers, grab bars, faucets, towel hooks, mirrors, lighting fixtures, and even floor drains. 

The risk of self-strangulation exists even at low heights. Some individuals have been known to attach a ligature to a low-level fixture or shower drain and their necks, then rotate their bodies to tighten the ligature, causing asphyxiation. This method is sometimes referred to as an “alligator roll” or “crocodile roll.” 

Figure 2 shows a ligature-resistant bathroom. The shower and sink faucets have a conical design while the accessories — mirrors, shelves and toilet paper holders — all have sloped edges to reduce ligature points. The sink and toilet have tamper-resistant shrouds covering them, and the floor drain is designed with an internal gusset system in the grate assembly to help minimize ligature points. The grab bars are completely enclosed, and the flush valve is hidden behind a tamper-resistant cover. 

It’s important to point out that the design is not institutional. Reducing stigma is a top priority for behavioral health-care providers, so the practice of installing penalware in these facilities is no longer acceptable. 

Additional considerations to keep in mind when it comes to designing and plumbing a ligature-resistant bathroom are:

• Cost-effectiveness. Budgets are a significant driver in what facilities can and cannot do. By choosing products that are durable and easy to install, facilities can save on replacement, repair and construction costs.

• Retrofitability. Many projects will be upgrades to dated facilities. By choosing products that work with existing walls and rough-ins, plumbing engineers can reduce the construction budget and mess while still delivering the aesthetic the facility is looking for.

• Universal design. Inpatient behavioral health-care facilities commonly include a few ADA-compliant and bariatric rooms. However, because of a system-wide shortage of available space, they do not want these rooms to be empty “just in case.” 

Universal design solves the problem of space constraints. All rooms are built to accommodate all patients, so facilities are always prepared.

• Quick installation capabilities. Every hour a room is under construction is an hour when someone is not getting the help they desperately need. Many ligature-resistant materials in use today are designed for quick and efficient installation.

3 Critical Factors in Project Planning

If you bid on or work in behavioral health facilities, consider these three key factors that could impact your design choices. 

1. Budgets 

Currently in the United States, about 14,700 facilities are designated to provide substance use treatment services, and about 9,500 offer mental health services, according to the KFF (formerly the Kaiser Family Foundation). Yet obtaining treatment is difficult due, in part, to the shortage of behavioral health-care beds in this country (https://bit.ly/4cIypMl). 

The Mental Health Parity and Addiction Equity Act was established to ensure equal treatment coverage for mental illness and addiction; however, many facilities don’t have excess funds to invest in their facilities. Many health-care facility budgets are funded through Medicaid and Medicare reimbursement, which will significantly impact their design choices. 

To balance safety, cost and functionality, it’s important to specify fixtures and accessories manufactured from durable materials and promote ease of maintenance. This ensures that new and renovated facilities remain safe and secure for future patients. 

2. Retrofitability

Retrofitability is another important consideration, as many buildings used for behavioral health care were built when asbestos was still used. By recommending fixtures designed to fit existing walls, rough-ins and carriers, there is no risk of releasing dangerous particles, saving the facility owner the cost of asbestos mitigation. 

Be sure to know your owner’s budgets before making recommendations. An extensive list of design options is available to ensure good patient outcomes. Do your research and demonstrate cost savings for each ligature-resistant element specified. 

3. Patient Population

Understating the patient population of the facility you are working with is essential, since different populations affect design decisions. 

For example:

• Children may require smaller fixtures and additional safeguards against scalding.

• Teens might need more robust fixtures to withstand potential misuse or vandalism.

• Adults could require a balance between independence and safety features.

• Elders may need bathrooms with enough space to accommodate the patient and caregiver and fall prevention measures.

Collaboration and Communication

Successful plumbing design in behavioral health facilities hinges on effective stakeholder collaboration and communication. Plumbing engineers must work closely with facility owners, architects and other design professionals to create safe, functional and therapeutic environments. 

By fostering strong collaborative relationships and maintaining open lines of communication, plumbing engineers can ensure their work integrates seamlessly with the facility’s mission, enhances patient care, and meets critical safety and functional requirements. 

Understanding the owner’s philosophy is crucial for plumbing engineers working in such facilities. It’s essential to grasp the facility’s overall mission and approach to patient care, as this understanding will inform every aspect of the plumbing design. For instance, a facility focused on immediate crisis intervention may have different needs than one specializing in inpatient care. 

Plumbing engineers must align their solutions with the facility’s long-term goals and budget constraints, ensuring that chosen systems and fixtures are safe, effective, sustainable and economically viable over time.

Working closely with architects is another vital aspect of successful behavioral health facility design. Early collaboration in the design process allows for the seamless integration of plumbing systems with architectural safety features, such as high ceilings and recessed sprinkler and lighting systems. This might involve coordinating the placement of piping and fixtures with the overall layout to minimize potential hazards. 

Aligning plumbing design with overall built environment goals ensures a cohesive and effective facility. 

Plumbing design should also support the therapeutic environment. For example, the trend in flooring is sound-reducing vinyl and linoleum products, so drains must be designed to fit seamlessly. Designers also want to ensure plumbing fixtures don’t interfere with security camera sightlines or electrical safety measures. Contributing to the facility’s sustainability and efficiency goals through plumbing choices might involve specifying water-saving fixtures or implementing greywater systems where appropriate. 

Finally, adapting plumbing designs to support specific treatment modalities or facility functions is crucial. This could mean creating specialized hydrotherapy areas for certain treatment programs or ensuring that plumbing systems can accommodate the unique needs of different patient populations, from pediatric to geriatric care.

Navigating Standards and Regulations

There is a severe lack of national standards regarding behavioral health-care facility design. Standards vary from state to state and are often very vague. For example, a regulation might state that “faucets should be ligature-resistant” without specifying what constitutes ligature resistance in shape, size or mounting method.

Due to vague language, different inspectors or facilities might interpret and implement the same regulation differently. Because of this, developing expertise on the most recognized standards will make a plumbing engineer more of an asset to the architect, general contractor and facility owner. 

The following is a list of key organizations and resources to help you understand the complexities of behavioral health facility design and keep you informed on current trends and challenges in the field:

• The Joint Commission is an essential source for Medicare and Medicaid reimbursement (www.jointcommission.org). The Joint Commission sets standards based on the Centers for Medicare & Medicaid Services. Accreditation is widely recognized throughout the industry.

• The New York State Office of Mental Health (NYS-OMH) provides comprehensive guidelines for patient safety standards, materials and systems, especially Division 22 (Plumbing) and Division 10 (Toilet Accessories) (https://bit.ly/4co4oRq). This guide contains information about the state’s different patient populations and is widely referenced even outside New York.

• The U.S. Department of Veteran Affairs’ “Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities” offers detailed guidance for inpatient mental health facilities, including diagrams and design rationales (https://bit.ly/3YJBfxe).

• Behavioral Health Facility Consulting publishes the “Behavioral Health Design Guide,” a valuable resource for standard adult psychiatric inpatient units (https://bit.ly/3M9GDBX).

• The American Society for Health Care Engineering (ASHE, www.ashe.org) provides resources and networking opportunities for professionals involved in health-care facility design and operation. 

• The Center for Health Design (CHD, www.healthdesign.org) is an organization geared toward health-care providers, facilities professionals, architects, designers and product manufacturers. It is an excellent place to familiarize yourself with the trends in the built environment. 

The Bigger Picture

Plumbing engineering in behavioral health facilities presents unique challenges that demand specialized knowledge and skills. From understanding ligature resistance to navigating complex regulations, the role of a plumbing engineer in these environments goes far beyond traditional design and installation.

By educating yourselves on the specific needs of the behavioral health community, you become invaluable assets to their clients. This knowledge allows you to contribute meaningfully to patient safety, support therapeutic environments, and help facilities meet crucial accreditation standards.

Understanding the intricacies of patient populations, budget constraints and evolving design trends enables engineers to offer innovative, cost-effective solutions aligning with safety requirements and treatment goals. 

Moreover, familiarity with resources such as The Joint Commission, the NYS-OMH, the U.S. Department of Veteran Affairs guidelines and organizations such as ASHE and CHD empowers engineers to stay at the forefront of best practices in this specialized field.

Traci Browne is a freelance writer specializing in manufacturing and engineering, and writes for Morris Group International.