By Laurence E. Hartman, AIA, CCHP; Gregory Cook, AIA, CCHP; Erin Persky, Assoc. AIA, CCHP
This article begins with a discussion of existing standards for correctional health care facilities, including strengths, weakness, and their applicability to modern correctional environments. Following this discussion is a description of an initiative by the National Commission on Correctional Healthcare (NCCHC) and the authors toward the development of correctional health care facility design guidelines that will be made available to architects and planners.
Existing Standards
By Laurence E. Hartman, AIA, CCHP
Correctional agencies are dealing with increasing demands to provide medical and mental health services for incarcerated populations. When construction funding is available, agencies will try to address this need through additions, remodeling, or new construction of varying size and complexity. These projects may provide complete medical and dental clinics as well as in-patient accommodations -- just as complex as facilities in the “free world”.
Regrettably, I believe there is a disconnect between the rigor of codes and guidelines in “free-world” health care facilities versus health care facilities in jails or prisons. I addressed this topic at the October 2016 National Commission on Correctional Health Care (NCCHC) conference. I presented an overview of selected codes and guidelines that are common to general health care projects which don’t automatically apply behind bars as well as those that do. I made the case for the development of a concise guideline for policy makers, planners, and architects covering planning of medical, dental, and mental health care facilities in corrections…but more on that in the last part of this article.
My research has uncovered a number of guidelines and standards which have practical application to health care in corrections:
Standards for Health Services in Jails (as well as Prisons, Mental Health, and Juvenile) published by the National Commission on Correctional Health Care. These standards have been developed to provide minimum levels of medical, dental, and mental health services in secure environments. They emphasize the systems, policies, and procedures that are needed to provide the appropriate care. Agencies can seek accreditation to prove standards compliance. They do not provide requirements that address physical plant needs.
Facilities Guidelines Institute (aka FGI) exists to “promote the process of producing consensus-based guidelines and publication, advised by research, to advance quality health care”. FGI does not specifically apply to correctional healthcare facilities; it is widely used for general hospitals. The FGI requirement for minimum clearance around patient beds or the requirement for minimum exam room sizes can be applied to corrections. There are numerous other relevant physical plant guidelines which are relevant to typical treatment and support spaces.
Standards for Health Services in Correctional Institutions (2003) is published by the American Public Health Association first written in 1976. This standard contains some specific requirements (such as exam rooms shall have 50 foot candles), but most of the standard merely uses the terms “adequate” or “proper”. In the section concerning mental health services, it requires that interviews and treatment sessions be conducted in a “confidential setting with auditory privacy”. In the section on dental services, it requires that the dental operatory includes panographic x-ray, sterilization, and other equipment if dental services are provided. There are minimal requirements specifically to physical plant, (such as 60-70 s.f. floor space for single cells and maximum decibel levels) but none are related to specialized health needs that would be found in FGI.
Standards for Psychology Services in Jails, Prisons, Correctional Facilities, and Agencies was published in July 2010 by the International Association for Correctional and Forensic Psychology. It is intended to provide guidance where mental health services are provided in secure facilities. It makes direct reference to NCCHC and ACA standards. It sets forth the requirement that minimum equipment must include confidential offices, lockable files, and alarm systems. They seem to emphasize the treatment provider rather than the patient.
ABA Standards for Criminal Justice – The American Bar Association has issued a set of principles and functional parameters for operating correctional facilities. Its emphasis is the protection of prisoner’s rights while promoting the “safety, humaneness, and effectiveness” of correctional facilities. It makes reference to “adequate” facilities while not defining what that means. There is a significant statement: “Hospitals and infirmaries should meet licensing standards applicable to similar, non-prison hospitals or infirmaries.” It is common for correctional agencies to limit the influence of health departments on their physical plants.
Hospital Accreditation Standards are published by The Joint Commission which accredits and certifies thousands of health care organizations. There are specific physical plant requirements in these standards for the “free world” that could apply to corrections. For example, a hospice program requires a 100 square foot single room or 160 square foot double room, a staff call system, nor more than two patients per room, and suitable furniture.
Guidelines for Environmental Infection Control in Health-Care Facilities available from the Centers for Disease Control and Prevention (aka CDC) provides useful information to prevent contamination that could lead to illness and lawsuits not just in the medical areas. Areas covered include “dirty” versus “clean” traffic flow, hand washing, seamless flooring, negative air pressure, ice machine cleanliness, etc.
Jail Design Guide, 3rd Edition is available from National Institute of Corrections. It originated in 1988 as “Small Jail Design Guide” in reaction to ineffective and outdated jails. Chapter 16 has a narrative on planning for medical isolation and medical housing. Chapter 17 covers health care in the jail through references to NCCHC and ACA as well as some specific minimum room sizes.
Institutional Support Space Standards is written by the California Department of Corrections and Rehabilitation. This level of detail is unusual for a state agency, but is very useful in the approach to the scale of physical plant requirements based on the size of the facility. There are specific medical room size references that could be useful outside of California.
Design Guide for the Built Environment of Behavioral Health Facilities is provided by the National Association of Psychiatric Health Systems to enhance the safety of adult in-patient behavioral healthcare units. There are useful reference to products that may apply to special housing units in corrections.
On the international front, the International Committee of the Red Cross seeks to ensure humane treatment and conditions in corrections. It contains a brief narrative on “health clinic” but has no specific physical plant requirements. The World Health Organization has published “Water, Sanitation, Hygiene and Habitat in Prisons”, which is primarily a policy document with no specific space requirements. It espouses the “patients not prisoners” view and the importance of the professional independence of health care decisions (similar to NCCHC policy). The document discusses the close relationship between prison healthcare and community healthcare.
NCCHC Design Guidelines Task Force
By Gregory Cook, AIA, CCHP and Erin Persky, Assoc. AIA, CCHP
Proper planning of a correctional health system is essential in establishing a basis for proper care and security within a new facility, whether it is new or renovated. The planning process requires appropriate resources and is collaborative in nature.
It is estimated that 40% of state and federal prisoners and jail inmates have a chronic medical condition.[1] The percentage of inmates with mental illness continues to rise, stressing correctional systems that are poorly equipped to provide adequate treatment.[2] As facilities adapt to provide expanded health services, administrators, planners and designers require access to the best and most current information as it relates to correctional health care.
The efficiency and effectiveness of the health program depend, in part, on the physical environment in which it functions. In the past, design considerations were driven almost entirely by security, with little thought given to the impact of the built environment on treatment. More recently, architects have become more focused on restorative design concepts which eliminate environmental factors that are known to be stressful or can have direct negative impacts on outcomes.[3] Research indicates that certain environmental features can calm patients, reduce stress, and strengthen coping resources and healthful processes and thus support better care outcomes in a health setting. The majority of correctional health facilities in the country, as currently designed, fail to meet the needs of a restorative criminal justice system.
Even though planning for the health unit is a critical activity[4], there is no comprehensive source for health care related design information in correctional settings. The American Correctional Association (ACA) provides the closest approximation, but their standards focus primarily on security issues and do not include consideration and assessment of treatment requirements. Therefore, the need for a comprehensive set of guidelines for the planning and design of correctional health facilities is urgent and clear. A database of ‘Best Practices’ would provide access to critical information related to facility planning to promote designs that support treatment and recovery.
In 2015 a task force was convened by the NCCHC to develop consensus on specific positions and establish a set of guiding principles. The task force includes NCCHC leadership and subject matter experts, architects, correctional health professionals, and other consultants experienced in and committed to correctional health care.
The task force has identified a preliminary set of goals, which include:
- Designing facilities that align with the health standards of the NCCHC, one of the preeminent correctional health care standards in the United States.
- Protecting the health and safety of visitors, employees, and patients.
- Promoting staff and operational efficiencies, improved communication, and collaboration.
- Incorporating Evidence-Based Practices, which utilize scientific evidence to evaluate risks, assess needs, and direct resources effectively.
In addition to these goals, the guidelines will be written with consideration of a number of requirements pertinent to the success of their application within a correctional healthcare environment. These include the enhancement of patient and staff safety, identification of and attention to the needs of the populations served (e.g., special needs of elderly, bariatric, terminal and other higher-risk patients; acute or chronic conditions), incorporation of technological innovations used in non-correctional healthcare environments, and wellness and therapeutic environmental considerations. It is also a priority to ensure that all guidelines are justified by existing, up-to-date research.
Care does not occur solely within exam rooms, and attention must be given to many areas in order to create a successful correctional health care facility. As such, the guidelines will be written to include recommendations for intake and discharge areas, pharmacy, and health care support areas; all levels of medical and mental health housing; patient interview spaces and group therapy rooms; and staff meeting and training areas, offices, and support spaces. Privacy issues, lines of sight, optimal adjacencies, and other special design considerations will also be discussed at length. Plans, diagram, and existing examples of best practices will be provided when available.
It is the collective belief of those on the NCCHC Design Guidelines Committee that the correctional healthcare physical environment has a significant impact on quality of care and outcomes. We hope to strengthen the relationship between the NCCHC and the AAJ in the coming years through the development of these guidelines and other initiatives aimed at creating optimal treatment environments within correctional settings.
The guidelines are still under development. Upon publication, a notice will be released in the AAJ newsletter. Stay tuned!
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Laurence E. Hartman, AIA, CCHP is an architect with HDR Inc. Larry.Hartman@hdrinc.com
Gregory Cook, AIA, CCHP is an architect with HOK. Gregory.Cook@hok.com
Erin Persky, Assoc. AIA, CCHP is a planner with Jay Farbstein & Associates, Inc. erinpersky@gmail.com
(Return to the cover of the 2016 AAJ Journal Q4 issue)
[1] Laura M. Maruschak, ‘Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-2012,’ US Department of Justice Office of Justice Programs, Bureau of Justice Statistics (February 2015)
[2] Gary Fields and Erica E. Phillps, ‘The New Asylums: Jails Swell With Mentally Ill,’ The Wall Street Journal (September 25, 2013)
[3] Cynthia McCullough, Evidence-Based Design For Healthcare Facilities (2009)
[4] National Commission on Correctional Health Care, Correctional Health Care: Guidelines for the Management of an Adequate Delivery System (2001)