Oh.

Hi, everyone.

Well, also, you know me.

I'm, Roxana Jafari.

I'm an assistant professor here at the School of Architecture.

Actually, College of Architecture recently, and, I've been working in healthcare design for, quite some time.

I got my degree in healthcare design from Clemson University, and I've been working there as a researcher.

And then I've been serving as an assistant professor in Lawrence Technological University in Michigan.

And then I joined Texas A&M University last year, and I've been teaching healthcare design studios.

I think conducting research in the lab that we have, arc for health.

And today I actually want to give you a quick review of a research project that, we conducted during summer.

And it was focused on the design of mental and behavioral crisis stabilization units, or what we call as excuse for, a adolescence.

That was the population that we mainly focused on.

And I want to review the, specific approach that we looked into this topic to build on the existing research.

So, the reason that we started looking at this topic was that, as we, were conducting, studio focused on mental and behavioral health through our collaborative, design studio with Canon Design, we noticed that there was a lack of research in this area.

Just to give you a little bit of background about what we did, we actually put together a panel of experts for this studio who guided us through research.

And there were basically the mental and behavioral health practice leaders, from across the US.

And also some of them are active international who joined our studio during spring of 2024 and they, participated in the Art for health lecture series.

So they provided case studies and cutting edge research, descriptions for our students.

And then they joined the studio and conducted desk critiques with our students.

So you can see different reviewers from, firms like HDR architecture, plus and Perkins and.

Well, and there were many more.

I just brought a few examples for you.

And as a result of these, research collaborations, some students started developing concepts for, designing mental and behavioral health facilities and some particularly focus on the design of crisis stabilization units.

And that was where, our discussion kind of started.

And the same students who were working on this topic specifically joined the, workshop that we had during the summer of 2024.

And we started working together to optimize the spaces, that, was providing care for mental and behavioral health patients, mostly adolescents and some architecture firms were also very, very interested in our work, including Virginia Pankey, that you saw in the pictures earlier.

She was interested in the work from the beginning, and she also joined us on this collaborative research initiative and also Stantec was doing a really good work on mental and behavioral health care design, also joined us.

And we also got the support of furniture and manufacturers for mental and behavioral health, like Norris and Norris and Celeste.

They also supported this research, and they were excited about this.

And, we started working on the topic and our first aim was to understand care processes, staff workflows, and also the built environment features that were necessary to be included in this environment to make it safe and, basically serve the needs of adolescents in the CSU's.

And that was where we started.

And right now we're, about to start in 23.

So I'm mostly going to cover, what we did for A1 in this presentation.

And it was really significant for us to look at this topic, as I mentioned, since, we noticed that, for CSU's, if, you know, there are environments, safe environments for mental and behavioral health care patients who, basically want to receive care in a safe environment.

And, mostly when patients experienced mental and behavioral health crises, they're taken to emergency departments, which, as you know, are chaotic, they're stressful, and they're not really responsive to the needs, particular needs of these patients.

So instead of, taking these patients to emergency departments, we take them to CSU's, which can provide a safe environment for them so that they receive the best care possible.

And this was based on the model, the impasse model that Doctor Zeller, mentioned.

And and that model and idea is, consistently growing as, we are basically moving forward.

However, despite all the progress that we have been witnessing recently, we see that in, some of the, states across the US, we do not see enough of these facilities available for patients, including the state of Texas.

And that was one of the reasons that we decided that it is necessary that we do research and try to expand on this area and optimizes the spaces, especially for children and adolescents.

So, let's talk about how we actually did this research.

We started with conducting semi-structured interviews with a panel of experts.

So we had 14 experts who were psychologists, psych, psychiatrists, psychiatric nurses, behavioral health practice leaders who joined us through zoom interviews.

And we talked to them, and we just wanted to understand the overall environmental features, workflows and safety issues that might happen during care processes.

And then based on all the discussions that we had with these experts during the interviews, we were able to create training maps for patients, for staff who are present in the key issues.

And then based on all the information that we got during the research that we did at the initial phase of, our workshop, we were able to conduct scenario based simulations.

So we built an actual, full scale physical mock up of the whole unit, including the observation lounge, the consultation rooms, seclusion rooms, quiet rooms.

So the whole unit was modeled at the rally's campus in.

Brian, if you know, we have a big warehouses over there that we can use to basically construct and test our models.

And then we were able to hold simulations with our experts and also a group of, designers.

The graduate students from Texas A&M University also joined us.

And, we tested different scenarios with them as well.

In addition to the experts, clinicians who provided feedback for us.

So and I clicked on the wrong thing.

Here we go.

So let's see what the interviews showed us.

So based on the interviews which each of them lasted about 60 minutes, we got a series of quotes and most of the quotes focused on environmental features followed by care processes, workflows for these patients and also outcomes, care outcomes.

And some also covered some interviews, covered building codes and regulations that are involved in order to build and you know, establish these units and you can see, some descriptive analysis for the information that we obtained from our experts.

So in terms of building codes and regulations, you can see that mostly our designers, behavioral health practice leaders covered those codes and regulations.

However, you can see that the clinicians were most excited about the care outcomes, like, for example, what outcomes they're interested in, in terms of comfort, in terms of safety and also clinician workload.

They mostly covered areas regarding that.

And when it came to environmental features, designers really elaborated on which features, are necessary for us as design designers to pay attention to and optimize these environments, such as access to certain areas, control and choice for patients and staff, and safety features like, for example, until ligature, qualities of furniture and items and institutional look and feature as positive distraction sources.

And also another topic that was widely covered was regarding furniture type and layout.

Because furnitures, the furniture types that we see in CSOs, are the main source of, you know, unsafe situations because they can be picked up and thrown at other people and create unsafe situations.

If we have an agitated patient in the unit, and also in terms of care processes, you can see that both designers and clinicians covered, these topics.

And it was very interesting to see that designers were, as knowledgeable as clinicians, regarding to care processes and different steps of care that the patients received upon arrival to the unit, and some instances of, the interviews that you can see, for example, regarding safety designers mentioned, that while chairs or furniture pieces have to be, basically heavy, sturdy and hard to be picked up by patients, and that's very important to ensure safety in these areas.

For example, one clinician mentioned that Ottomans that are smaller and they can be picked up and are less heavy should be avoided because they can create they can be used as weapons and create unsafe situations.

And clinicians also talked about, control and autonomy because most of the patients who arrive at these units that are very they might be anxious, stressed, they are supposed to spend about 24 hours or in some cases more in these units.

So we need to, be able to provide, stress with the, and basically a place that can help them with reducing their stress levels.

So that's really, really important for us to do that.

And also, they mentioned, access to certain areas, let's say nourishment areas that are usually provided for CSU patients.

But as we know, for example, if you provide hot coffee in the nourishment areas for patients, that can again be an opportunity for an unsafe situation.

If you have an agitated patient, they might pick up that hot coffee and throw at other words and attempt to hurt others in the unit.

So it was very helpful for us to understand which areas of design we need to focus on in terms of improving and optimizing safety features in the unit.

And also another thing that was very helpful, we were able to, based on the interviews and the stories that the clinicians and designers were telling us, we were able to provide, the workflows and scenarios for receiving care, which helped us to create the scenarios that we wanted to test for the simulations.

And you can see, for example, another workflow for clinicians that were also shared.

And another discussion that, occurred during the interviews was mostly focus on the furniture layouts and furniture types.

And as I mentioned, we also had a furniture manufacturer who also joined us on this discussion.

And they provided samples of different furniture types and different layouts that we could see in the unit.

And during the interviews, we also got, the express feedback regarding some of the concepts that they had.

For example, one concept that the furniture manufacturer shared with us was regarding the color coded assigned seating options in the in the observation lounge for mental and behavioral health patients who were basically adolescents.

So we post that question and we wanted to understand what the experts would think about it.

And if it was actually a good idea.

And it was interesting to see some discrepancies in the feedback that the experts provided for healthcare designers.

When we asked that question, they mentioned that, oh, it's a very interesting concept, and we should definitely look into it and investigate it further.

However, when we share that idea with clinicians, they immediately mentioned that majority of them immediately mentioned that, well, this might cause conflict and power struggles and this might also add to the clinician's workload during care processes.

So we do not want anything that can interfere with our work and interfere with our work processes.

And this seems to be one situation that has the potential.

So, based on all the information that we got, we compiled all the data, analyze all the data, and then started constructing the full scale physical mock up, which was an interesting and a very exciting part of this.

And we have some students here in the audience who assisted with building this.

So, the way we started and this is the warehouse that we had available at rallies, we started with taping the ground to basically point out the floor plan and the boundaries that we were supposed to build.

And then we had, students develop strategies for, putting together the cardboard panels.

So we went for a low fidelity mock up that allowed us flexibility.

And, we use carports, which, again, allowed us to cut them very quickly with a lot of flexibility to change the concepts very quickly.

And also these connectors that the students built themselves manually allowed us to connect different panels and change their configuration very easily during the scenarios.

So this is a quick, video for you just to see, how the whole process happened.

Again, as I mentioned, we started with taping the ground and the students started cutting the cardboard, and it all happened during one week after we collected all the data and analyzed the data.

Yeah, the students worked really hard in this, and we got the furniture from the racks and also the recliner.

And as you can see over there was provided by the Celeste Durham Mental and Behavioral Health Manufacturers.

So we put together the furniture and our mock up was ready to be tested in simulations.

And we had a medication room nursing station.

It was the observation lounge, consultation room, the quiet room.

And also at the back you could see the seclusion room and the anteroom and their own bathroom areas.

So based on what we developed, then we started writing down the exact scenarios and people who were supposed to participate in those scenarios to simulate care activities.

So we had different roles nurses, patients, psychologists, psychiatrists, who were supposed to basically take part in the simulations.

And one scenario that we wanted to test was regarding, the the escalation process for an agitated patient with a high risk of harming themselves and others in that observation area.

And we wanted to simulate this, to understand which features of the, mock up that we designed was working well in terms of creating safety for the patient and the staff, and which features were not working well.

And, we had five experts, who were selected from those expressed that we interviewed taking part into the simulations.

There were psychologists and behavioral health practice leaders.

And also we had 13 graduate students who also participated as novice designers with less than ten years of experience in the field.

Who helped us with collecting data.

So let's see some instances of the simulations.

And this is a based on the simulated simulation session with the experts.

So you can see the designers over here.

We also had the clinicians.

So this designer was, impersonating an agitated patient in a milieu, who had the potential of harming themselves.

And others.

So you can see that she started throwing things at other people.

And based on what we actually simulated and as you can see, the comments regarding Ottomans, how easily they can be picked up and thrown at others, we tested all that to understand, the furniture type, whether, for example, they were working well, if there were a hazard, if we needed to rethink the furniture types.

So all of the design considerations were tested.

Another main design feature that we tested by, was regarding the design of the nursing station.

So we had two different design concepts.

One design concept was an enclosed nursing station with a barrier as, glass panels.

And the other idea that we had was a more open design for the nursing station.

And as you can see, the nursing station could be pushed more into the observation lounge to provide more opportunities for interaction with patients and also observations.

And we wanted to test it, with the scenarios to understand which design for the observation lounge was actually more optimal in the eyes of the participants.

So let's take a look at the data.

First.

The concept that we had regarding the design of the nursing station, you can see design one, which was the enclosed nursing station with the glass panels, separating the observation lounge from the nursing area.

And on the other side of the nursing area, we also had the medication room, which we wanted to keep away from patients, especially, due to the fact that we might have patients who are dealing with substance abuse.

So we wanted to, basically keep them away from those areas.

And as option two, we had, open nursing station, where there was an opportunity for people to interact more with the patients in the observation lounge.

And we asked the experts first to rank the visibility and also potential, chances for elimination of blind spots, because that can impact the level of supervision that they have in the unit.

And as you can see, they did not rank.

And, second design with the open nursing station that high.

So they ranked basically the first option, highly.

And it was kind of the same thing for privacy and also emergency access for patients.

The interesting part was when we asked the graduate students and novice designers with less than ten years of experience in the field, that novice designers really like the open nursing station concept, and we ranked it much higher in terms of visibility and elimination of the blind spots, and also in terms of providing emergency access for patients in that area, and also in terms of privacy.

That discrepancy was really interesting for us to see.

And also we asked, all the experts, participants who participated to select their survey types of furniture that they saw in the unit, and these were the types that were mostly selected.

They really like this armchair and rocker.

And also we had that specific type of recliner that was designed for mental and behavioral health patients.

And as you can see, the controllers for that recliner, it could be locked and, kept away from, the patients reach just to make it, you know, safer.

So to better understand the reason behind some of the choices that the experts made, we held focus groups after each session.

And we also, you know, obtained their idea using questionnaires, using, failure mode and effects analysis.

We were able to identify the moments that caused failure during care processes and score their risk to see which ones were of high risk and which ones were of low risks.

And this is the result.

So first let's look at what the experts said.

So for the enclosed nursing station they identified some basically design considerations.

So some mentioned the issue of visibility.

Some mentioned the issue of access.

For example, they mentioned that patients might still have some sort of access, visual access to the medication room for the open nursing station.

One of the things that they mainly mentioned as a downside was creation of blind spots.

And if you look at this image, you can see that when we push that nursing stations forward and more into the observation lounge, we create created instances where patients could actually hide and that could pose some risks, opportunities that, well, could cause harm for the nurses and also for the patients.

And these were the things that we definitely wanted to optimize and, not to include in the design of our units.

And we could see similar feedback from our graduate students and novice designers who participated in the simulations.

As you can see, and provided feedback.

They also mentioned the issue of visibility, that there was some sort of lack of visibility to certain areas, such as the quiet room, the seclusion room, even though we included that open nursing station and we were changing, modifying the design options.

And one idea that was covered by both the experts and graduate students, and this overlap was very interesting to us, was that both groups mentioned that we would need a secondary point of access, a second door on this site in terms of emergency to, make it possible for the nurses to have, quicker access to patients if something happens to them.

Based on the current design that we had.

We only had one door that connected the observation lounge to the nursing area by both groups.

The experts and the graduate students mentioned that that was not enough, and we needed a secondary point of access.

So moving forward, we will focus on, the ambient features inside the observation lounge and also, the overall unit to understand how we can optimize some features, such as, for example, lighting, such as access to views or patterns that resemble natural patterns.

And to do this we are incorporating generative AI.

So we use the images of the carport mock up that we had, and we use it as input for the generative AI.

And we use prompts to see, what images, generative AI, what ideas, innovative ideas.

It can propose, it can show us.

And if you look at some examples, you can see that AI is capable in terms of understanding, for example, biophilic design features.

When you ask AI to provide visual access to greenery, or to implement, for example, natural elements like wood, it is absolutely capable of understanding this, and it can build on the design that you have.

And, improve it.

However, the biggest downside of generative AI is that it still does not understand safety features.

For example, one of the things that it kept changing in these iterations was the material of the furniture.

So we want to avoid cushions for the furniture in these areas because we want to make sure that, all the items furniture are ligature resistant and they cannot be tampered with.

But I does not understand it.

So when you actually ask it to improve the quality of the environment, lighting, the materials, it will change the materials.

So we need to find a way to train it and make it understand when we talking about safety and health design environments, exactly what we mean.

And also training to learn to stick with the codes and regulations.

Because we have a lot of them in healthcare design.

So training AI to understand it and implement it when it is generating new images and renderings.

This is one of the key things that we are now working on.

So that's going to be our aim to.

And finally, based on the approach that we implemented, which was a combination of making physical mock ups, constructing physical mock ups for the full scale, and also, using generative AI to guide and provide feedback regarding our next step.

This is going to be something that, we will cover and work on, and we will provide hopefully a set of evidence based recommendations to help with future designers designing and building these environments.

So just to summarize what we covered during this presentation.

So it was exploratory pilot study that we did.

And we focused specifically on crisis stabilization units, see issues.

And we did a lot of focus, focused work on the observation lounge, where we have a group of patients receiving care.

And we also focus specifically on adolescence, because we realized that there is not enough research on, how these areas can best response and respond to their needs.

And we talked to a panel of experts, and based on the interviews that we held with them, they emphasized some design features, some desired features in these units, including choice and control and including safety considerations like, for example, ligature resistant features or certain materials or access points that should be provided or not provided in the unit.

And also, there were lots and lots of discussions regarding furniture type and layout, which I just briefly mentioned.

And hopefully in the future presentations and papers, you will see the full report of all the, features and qualities regarding furniture that they covered in this study.

And also what was interesting was that when we tested two different ideas for the, mock ups, including the open versus enclosed nursing stations, and depending on how experienced our participants were, we heard different comments and, different evaluations of these ideas.

And also when we were evaluating furniture between clinicians and designers within the same expert group with the same level of experience.

Again, we noticed some discrepancies in the evaluation of the furniture, like, for example, the color of the furniture and materials layout.

So it means that if you want to improve the safety and quality of these environments, we really need to have this discussion with different people involved in the design process, including clinicians, designers, furniture manufacturers, to ensure that we're all on the same page.

And we have a good understanding of the specific needs of patients to be able to optimize these environments.

And hopefully, as we built on this methodology and integrate construction of the physical mock ups with generative AI, we would be able to facilitate this whole process for the future designers and, clinicians taking part in these processes.

And finally, a huge shout out to the research assistants, the team who helped us with, this workshop and made this research possible.

And also, a huge thank you to our sponsors, Nordics Behavioral Health Care, and also Salus for supporting this study and the Department of Architecture.

There are a lot of people to thank.

So yeah, and that was the project that we did.

So let me know if you have any questions.

Yes okay.

Yeah.

Let me give you the mic.

Alondra.

Here we go.

Thank you.

So when design us.

Yes.

Yes okay.

Did you hear that echo when I was talking as.

I'm so sorry.

I know you know this is okay.

Here you go.

When designing this, the excuse for their different levels was this, plan to use it for all types, extremities or, extreme, or was it really just for one case scenarios of people coming in certain needs?

Great question.

Thank you so much for bringing that up.

So we initially, intended to create, a CSU that would be responsive to a variety of acuity levels, patients with different types of acuity levels, high acuity, moderate levels of acuity, and low acuity.

However, this was a pilot study and well, we had a limited number of participants and we just we have just initiated this study and we the, scenario that we considered was for a high acuity level patient, a highly agitated patient who was prone to harming themselves and others.

So we were we're intending to test more scenarios with patients who are in a less, you know, acuity level, and they would basically receive observation and care in the milieu in the observation lounge and then go home.

But the scenario that we tested was an agitated patient.

Thank you.

Sure.

Yes.

Oh, thank you.

So looking at the private spaces where the patient can see by themselves.

Measures where they're like self-harm like like a germ resistance in the bathroom.

Right.

Well excellent point.

I'm not sure if I have detailed, images of those areas.

But you can see that for example, this is one sample of furniture layout that was the rocker that was included in the quiet room.

And so that patients could, basically relax and receive care.

So, again, the specific type of furniture that was ligature resistant, was, there and also another design consideration was that mostly if a patient is of high acuity, they're accompanied by the caregiver in all the spaces that they go.

So again, adjusting the doorways so that, you know, when, the patient with 1 or 2 caregivers start walking into the room, the door should be able to accommodate, you know, the caregiver or the patient.

So adjusting the width and the design of the door is was something to be considered.

And also if you look at these images, we have windows in all the doors which, were designed, the dimensions were designed in a way to allow visibility from the nursing station when the staff is present here, so that there was constant, you know, visual access to ensure safety for the patients.

Okay.

I have one more question real quick for the glass partitions for the nursing station.

Would that be shatterproof or some sort of acrylic so that, you know, they can't break it?

Absolutely.

Like, polycarbonate.

Glass that cannot be shattered by patients.

And in this and that was that was a great point that you brought up.

And in this simulation, we actually do you see the glass.

So we actually built it this way for the simulation purposes.

But in reality, because the base model that we used, it was actually obtained from an actual project that is that is currently working on however we modify that layout based on the research that the students have been doing during their studio project.

So in the initial layout that we got, that glass went all the way up to the ceiling.

So this was completely enclosed.

However, we made some modifications based on all the different data that we collected.

And to give you a little bit of background, what George was talking about regarding the Clemson project.

So, we worked on a $4 million project in collaboration with, Medical University of South Carolina on optimizing the environment in the operating rooms.

And this was a very similar approach that we did.

And, of course, after the low fidelity mock up with carports of the operating room, we actually did a high fidelity mock up, which we had actual, equipment or equipment booms and systems, and we brought in clinicians who were going to occupy the new building that we were designing based on the design ideas we're developing for the ORS to the mock up and simulated the whole surgical procedures that that we're doing.

And they provided feedback for us step by step.

Which aspect of the design of the O.R.

was working well for them?

Let's say, for example, in terms of equipment placement, the angle of the bed, every little detail could make a huge difference in the outcomes, patient outcomes, during the surgical procedures.

So, we did four years of research.

And finally, the layout of the O.R.

that was developed was implemented in a new, ambulatory surgery center that was built in Charleston for ambulance CE.

So, as you can see, all of these, research projects that we do, it can be very impactful and it can make a huge difference in terms of how, staff were occupying this building, how patients who will be using these buildings, can stay safe and recover.

So just a quick feedback.

And yes, George, to your point, I showed them the videos for the simulations that we did.