Michael De Cicco, Author at Social Current

In the high-intensity, resource-scarce universe of human services, the service environment itself often gets overlooked, or else overshadowed by compliance concerns. Against the backdrop of serving families at risk, individuals in crisis, and struggling communities, all while trying to keep the doors open, space planning concerns like layout, furnishings, lighting, and décor can seem trivial. Facility design might sound like a luxury, but in reality it has a presence in almost every aspect of service delivery. The evidence is clear. The physical environment can have a profound impact on behavior, mood, perception, and accessibility. When designed intentionally and strategically, your facility can support the work and mission of the organization. Left unexamined, it can limit or even undercut your impact.

Whether you’re opening a new site, considering a relocation, planning a renovation, or just looking for ways to refresh your facility in a way that improves the effectiveness of your services, here are some important issues to consider:

Safe space

The most fundamental concern for every organization is safety. Every facility has to comply with building codes and regulations aimed at protecting occupants from hazardous conditions. Features like emergency exits are specifically designed to promote safety by influencing behavior in the event of a critical incident – such as evacuating during a fire.

Serving vulnerable populations, however, often means preparing for and responding to critical incidents stemming from distress, conflict, and harmful behavior. In recent years suicide prevention has become a focal point for facility planners and is emerging now as a powerful example of how the built environment can be leveraged to save lives. Organizations serving populations at risk for suicide are embracing the imperative to scrutinize all architectural features, fixtures, and materials in the service environment for their potential to become an instrument for harm – specifically as an anchor point or ligature. Shatterproof glass, round-edged doors and tables, breakaway curtain and closet rods, and tamperproof power outlets are just a few examples of features that have been designed to be suicide-resistant. The layout of the service environment can also play a role in reducing opportunities to self-harm; placing staff areas in close proximity to high-risk individuals allows for consistent yet non-intrusive observation.

A trauma-informed approach tells us that identifying and addressing triggers or trauma reminders is key to preventing and de-escalating crisis situations. Organizations must examine both the physical and psychological safety of their facilities and keep in mind that the built environment itself can be a trigger or stressor. An enclosed, restrictive space can often be triggering for individuals with trauma histories or individuals with certain mental disorders, such as schizophrenia; this is often addressed by foregoing corridor layouts and installing glass doors that enable individuals to get a clear view from one service area into the next. Planners also often avoid using the color red to avoid associations with blood, fire, and emergency lights that can trigger a trauma response. Individuals coping with anxiety or PTSD can be overstimulated by patterns, brightly contrasting colors, or other visually complex designs; neutral or softer colors with more subtle transitions are therefore generally more appropriate for therapeutic environments.

While safety is imperative, there are plenty of other ways the built environment intersects with organizational goals and priorities. Now that we’ve looked at how the physical environment can reduce suicide, harmful behaviors, stress, and aggression, we can turn to how it can reinforce and encourage positive behavior and promote better client outcomes.

The client experience

A well-planned facility should complement your organization’s work by ensuring that individuals and families feel safe, supported, and in control while they are receiving services. To learn more about how organizations use the built environment to support their work, we spoke with Children’s Institute, Inc. (CII) in Los Angeles, a COA-accredited organization that provides a broad array of mental health, early care and education, child welfare, family support, and youth development services to children and families – who are also currently in the process of relocating one of their sites and constructing a new campus.

A client-centered approach informs many of the crucial decisions CII has made in identifying and designing their new facilities. “We thought about how it would affect the client’s experience, being on one floors or two,” says COO/CFO Eugene Straub. CII has been careful to ensure that their facilities are welcoming to both clients and staff. “The goal is building a sense of trust and security. The last thing you want to do is make anyone feel uneasy.” Improvements have also been made to existing sites where the space was not meeting families’ needs. “We had a nice lobby and waiting areas but there were no activities, and we looked for ways to change that and make the space more inviting and inspiring.” Now CII’s once-empty waiting areas include a lending library and creative space for children and families to use.

What are some ways that your organization could find inspiration and ideas when planning facilities? Your service recipients, staff and community are a great resource for ideas and a great place to start. Organizations should always look to their service recipients and their communities for ways to enhance their service environment, and tailor their facilities to the unique needs of the service population and to their service model. For example, a residential facility for individuals with schizophrenia can provide some relief to residents coping with paranoia by orienting beds and desks to face the door. A youth development program for children with autism spectrum disorder, who often struggle with spatial navigation and wayfinding, should consider applying visual cues to transitional spaces. Every organization’s approach to designing an effective and supportive service environment will be unique and depend on their scope, service population, service model, and culture. But there are a few universal design features that facility designers and environmental psychologists agree contribute to a calming, welcoming, and therapeutic service environment:

Nature equals nurture

Studies have consistently shown that access to nature, whether physical or visual, has a calming effect. Treatment facilities often situate themselves in a natural setting for this reason, but any organization can look to existing assets to bring to their full potential, such as a small outdoor space that can be converted into a courtyard or garden, or installing windows to take advantage of a good view. Organizations that are truly limited can still make enhancements by incorporating plant life into the decor and displaying nature and landscape art, which have also been demonstrated to have a positive and calming effect on mood.

Let the sun shine

Sunlight triggers the release of serotonin, which boosts mood and focus. Research also indicates that the ability to identify time of day through observed sunlight is conducive to re-establishing perception and natural thinking while minimizing disorientation. Natural light also makes small spaces appear larger and more open than they are. Organizations should ensure that they’re maximizing and not obstructing their natural light, such as by moving furniture away from the windows, using window coverings that filter rather than block out sunlight, and opening up any doors and windows that would allow natural light to pass through the facility. Transom lights (windows built into the space above a door) and skylights are also examples of architectural features that maximize sunlight while still preserving privacy.

Power to the people

A client-centered and trauma-informed approach to services stresses the importance of giving service recipients opportunities to have a voice in their service plan and at each stage of service delivery. For survivors and individuals coping with past trauma, opportunities to take control and make their own choices are important exercises in self-empowerment and essential steps on the road to recovery. Current best practice regarding residential facilities stipulates that residents should already be encouraged to personalize and decorate their own space. However, when possible, personal choice should also be extended to the environment by giving service recipients the power to customize lighting, temperature, acoustics, or furniture arrangements. To balance flexibility with safety, facility planners often choose furniture that is too heavy to be thrown or used as a weapon, but that can still be moved around and reconfigured, which gives individuals (or groups, in communal settings) autonomy to situate themselves where they feel safest.

No place like home

Experts typically agree that a safe, therapeutic, non-institutional and homelike environment is the best setting for residential treatment. Some strategies that designers employ to make a facility more warm and inviting include using upholstered rather than hard furnishings to invoke a softer, cozier feel, and mixing and matching a cohesive array of furnishings to avoid a uniform, institutional look. Given that “home” is a cultural construct, cultural competency is vital to ensuring that your environment meets the definition of “homelike” for your service population.

Of course, “home” is about more than just furniture — it’s also about people. When designing or evaluating a facility, organizations must consider not only the service recipient, but their support network. Because an engaged and committed support network is one of the most important contributing factors to positive client outcomes, service environments need to promote and facilitate their ongoing involvement. Organizations should be mindful that an imposing service environment can discourage or inhibit the service recipient’s support network, and evaluate whether their facility accommodates and encourages visiting family and friends as well as any collaborating service providers. Is it intimidating for visitors to access or navigate the facility? Are there welcoming spaces for residents to spend time with their visitors, or to have private conversations?

Supporting your staff

Getting your space to work for your service recipients also means ensuring that it works for your workers. As with service recipients, the environment influences workers’ behavior, mood, and functioning – which in turn impact performance and productivity, and your organization’s effectiveness. In human services, an ineffective environment undermines not only your bottom line but your mission.

The human services field also faces significant workforce challenges – namely recruitment, retention, and secondary trauma. Qualified workers are in short supply, in no small part due to poor funding and stigmatization of the service population. Staff shortages and the difficult nature of the work, which often manifests as secondary or vicarious trauma, lead to burnout and to high rates of turnover. Finally, worker turnover negatively affects client outcomes.

These workforce challenges have been at the center of the design and planning process for Children’s Institute, Inc.’s new offices. With the aim of promoting collaboration and “addressing the adverse effects of the work itself”, CII decided to eliminate cubicles in favor of a communal, team-driven open plan layout that will allow staff to support one another, celebrate their successes together, and foster staff resiliency. Straub observed that the cubicle layout often forces staff “to go from meeting with clients to sitting at their desk by themselves” and process their experiences in isolation. The intent of the new layout is to encourage workers to “have more of a shared experience and focus on wellness and self-care both individually and with each other”. The new offices also feature “decompression zones” – calming work-free spaces for staff to recover, including through meditation and yoga, as well as larger common areas, kitchens, and breakrooms. Evolving workplace norms mean that “the younger workforce wants an office space that fosters support and feels less corporate and more collaborative,” Straub explains, making these amenities not just “perks”, but rather, vital resources that will promote staff wellness and strengthen recruitment of valuable staff.

CII is also allocating space for “drop-in” staff – workers from other sites who are out in the field will be able to use nearby CII offices as a landing spot in between client visits. Straub envisions that this increased “cohabitation” will stimulate knowledge and resource-sharing and enhance linkages for families and continue to build the culture of the agency. Emphasizing the importance of “collaborating with the end user,” CII has also been careful to engage staff in the facility planning process, bringing all staff to tour the new space before signing the lease and soliciting feedback about the environment as part of annual employee surveys. Continuous assessment of a new or revamped workspace is not just good quality improvement practice, it also ensures that the organization identifies and addresses any unforeseen effect on employee functioning. For example, in an evaluation study of behavioral health facilities, researchers discovered that staff in a new facility that had been designed to promote client-staff engagement were experiencing greater burnout in response to the increase in client interactions.

Strategic plans to building plans

Creating a safe, effective, and supportive service environment requires the organization to approach the physical environment as part of its mission. It calls for not only commitment and investment, but also a shift in attitude — away from “being happy just to get the space”, as Straub says, and towards leveraging the space to influence how the organization’s operations are experienced and perceived. By tying together their facilities, mission, and strategic plan, CII’s ambitious expansion project received enthusiastic support from its board and funders. Straub sees the new campus as “an opportunity to create organic change” by leveraging the space to build partnerships with the community; plans are already underway to co-locate with other providers and host community taskforces and other grassroots organizing initiatives.

As much as we’d like the primary takeaway here to be “good facility design is not about aesthetics”, it bears noting that a well-designed facility achieves through its appearance two invaluable objectives: firstly, it destigmatizes the organization’s services and service recipients, and secondly, illustrates the depth of the organization’s commitment to the community.

Tell us in the comments: How has your organization used its facilities to support service recipients and staff? What would you change about your current service environment?

1. Differing visions: Compliance vs. quality improvement

A shared, clear vision of what QI means internally is critical. Is your organization solely focused on meeting licensing, funding, and regulatory body requirements, or is it determined to delve deeper to strengthen its practices on a continuous basis? It’s the difference between being compliance-driven and quality-driven. The Health Care Compliance Association defines compliance as “systematic procedures instituted by an organization to ensure that the provisions of the regulations imposed by government agencies are being met.” The operative word here is imposed – the organization is guided by deliverables set by an outside entity. Quality improvement includes aspects of compliance. Joseph DeFeo, author of Juran’s Quality Handbook, views quality improvement as being of “exceptionally high quality, defined only in terms of the organization’s internal standards.” Both compliance and quality improvement are connected to the same end user – the client — but success is defined in different ways.

A quality-driven organization begins with quality-driven leadership. Leadership is responsible for creating a culture of improvement guided by factors beyond the expectations of external entities, and they need to be significantly motivated by internal targets/goals. This requires that leadership embrace transparency, and not disregard information that may cast certain aspects of the organization in an unflattering light. Exposing organizational weaknesses is fundamental to improvement, and leadership needs to be straightforward about it early on as they develop and commit to a definition of QI that will lay the foundation for the work ahead.

2. “We have plenty of time!”

Building a QI system takes time, so it’s better to err on the side of caution and give yourself a lot of it. True, time isn’t always on our side, and often those who oversee QI activities do so on top of other responsibilities. Don’t let time be the enemy; start early, and begin by educating staff on all the moving parts that comprise a quality improvement program. This way they’ll understand why you’re starting twelve months in advance rather than three months prior to the target implementation date.

There are two major phases in this process: planning and implementing. In the planning phase, you need time to develop a work plan, meet with all programs and administrative departments to brainstorm metrics, create procedures, and put all the pieces together. Take into account that brainstorming sessions will likely take place over the span of several meetings. The implementation phase includes collecting, analyzing and reporting data, and meeting with different forums to discuss the information. These exercises shouldn’t be rushed, and may take significant time to complete.

In the implementation phase, it’s important to obtain staff feedback on data reports and analyses to ensure the information is clear, beneficial and useful. To get perspective and efficiently address barriers in the way of advancing your QI system, schedule on-going meetings with departments and programs to get their perspectives on pieces that do and don’t work.

3. Neglecting the power of cheerleaders

The cheerleaders are your champions – those who have informal and/or formal influence within the organization and can push the PQI agenda forward. Your cheerleaders understand the value of quality improvement and can explain its significance to other staff. They provide guidance and foster a culture of improvement by creating spaces for staff to get excited about data. How is this done? Adding QI to meeting agendas, providing additional context to data reports, or exploring obstacles to using data with staff.

Cheerleaders also support QI coordinators by offering tips on how to get certain busy individuals to meet their QI deliverables, or help determine when a task needs to be postponed or expedited. To implement quality improvement, you need eyes and ears on the ground to ascertain the organizational climate as the initiative is rolled out. Establishing a quality improvement system can have its challenges, especially when unforeseen hiccups occur. Champions can help you strategize how to achieve objectives and deal with underlying issues as they arise.

How do you know who your champions are? Meet QI cheerleaders, Nancy and Jesse…

Nancy, the chief operating officer, has oversight of the QI department at the organization. While the role of managing the agency’s QI system has been delegated to the QI coordinator, Nancy receives weekly updates on progress of the QI initiative. When she is informed that directors have been unresponsive to emails and meeting requests, in the next director’s meeting, she makes QI an agenda item to discuss the importance of the initiative and allow an open dialogue for questions and concerns.

Jesse, the office manager, has a warm and outgoing personality. He welcomes all clients and staff who enter the building with a smile. With his friendly demeanor and passion for helping others, Jesse knows most of the staff. He is just the person to bring excitement and energy to the PQI initiative. While he may not know all the ins and outs of QI processes, he is eager to learn and appreciates the benefits the work will bring. He asks many process-related questions about PQI strategies in the meetings that helps the team strengthen procedures and clarify responsibilities.

4. “Let’s skip the basics.”

Compartmentalize! Compartmentalize! Compartmentalize! Oh, and did I mention you should compartmentalize? Patience is key in the planning phase, but slow and steady wins the race. It’s important to start small so everyone is on the same page. You might have colleagues who are eager to start data collection and try to skip over important preparation steps, or those who want to focus on high level outcomes without first getting a solid foundation for the basics. Slow them down! Looking at basic output data may not be super exciting, but when developing a formal system, you want staff to understand (and follow) the process just as much as you want to be able to make inferences about the data generated. Data that supports what staff know anecdotally through program experience and data that contradicts it are both equally important. This is what makes an organization data-informed.

Meeting with programs to determine what indicators will be used to measure the impact of services on clients, also known as client outcomes, is an important step in developing your QI system. Once leadership approves the QI program, it’s easy to assume that all staff are on the same page in how QI is perceived and understood. This is not always the case, and it’s helpful to be prepared. Your colleagues may be confused, annoyed, excited, or anxious, about what needs to happen. You may need to train program directors, managers and staff about what QI means to the organization before you can explore the possibilities for outcomes.

Ideas for training? Provide context by talking about the history and how the organization has gotten to this point with its QI efforts. Make the training fun and encourage creative thinking with games or trivia. Use your cheerleaders to get others excited. Even if there is a desire for QI, there may be a gap in knowledge and skill that needs to be addressed. Provide clarity on the objectives to be accomplished and define key terms so that everyone is clear on the tasks and expectations. Share resources on data analytics, embracing change, and outcome measurement with colleagues so they may continually learn and challenge one another.

Final thoughts

The end goal is to develop a quality improvement system that provides a framework to use data to support decision-making and enhance practices. The culmination of all this hard work is an organization that is able to transform data into knowledge, and strengthen its practices to better meet the needs of its stakeholders. Remember, improving practices does not mean they were inadequate before. It is using a platform to evaluate organizational performance in a thoughtfully planned manner.