Minimizing Risks in Healthcare Environments

CPTED Minimizing Risks in Healthcare Environments Healthcare Online Learning Collaborative

October 21, 2015

Agenda 1

Learning Take-Aways

2

What is CPTED?

3

Why CPTED? Healthcare Context

4

Methodology

5

First Generation CPTED

6

Second Generation CPTED

7

Implementation

1

Learning Take-Aways

1. Understanding of basic first and second generation CPTED concepts 2. Why the healthcare industry could benefit from increased safety measures 3. How to evaluate a facility from a CPTED perspective through site tours, photos, checklists and user engagement 4. How to implement CPTED recommendations

2

What is CPTED?

Crime Prevention Through Environmental Design (CPTED) • Urban planning concept that involves manipulation of the built environment • Works to both discourage/prevent criminal activities and reduces fear of crime • First Generation vs Second Generation…

2

What is CPTED?

First Generation CPTED • Traditional CPTED concept

• Modifications to the physical infrastructure and built environment

2

What is CPTED?

First Generation CPTED 4 Main Concepts:

Natural Access Control

Natural Surveillance

Territoriality

Maintenance

2

What is CPTED?


Natural Access Control •

The physical guidance of people coming and going from a space, controlled through the placement of entrances, exits, fencing, landscaping, locks and other barriers. Example: A small swing door could be placed at the entrance to a nursing station as a barrier to unrestricted movement

2

What is CPTED?


Natural Surveillance •

The placement of physical features, activities and people in ways that maximize the ability to see what is occurring in a specific space. Example: Ensuring windows are barrier-free from signage or other materials to allow sightlines to and from the space.

2

What is CPTED?

Territoriality

Territoriality •

The use of buildings, fences, signs, pavement or other objects to express ownership or transitional areas between public and private spaces. Example: A door that states “Staff Only” makes a clear statement that non-staff members should not enter the space.

2

What is CPTED?

Maintenance

Maintenance •

The upkeep of an area demonstrates that someone is maintaining it and watching. Neglected space can encourage an environment where people mistreat space, while maintained space can encourage proper treatment. Example: Littered cigarette butts in a nonsmoking area can further encourage this prohibited activity.

2

What is CPTED?

Second Generation CPTED • Supplemental extension to first generation CPTED

• Focuses on explicit social and cultural dynamics of the environment • Analyzes existing policies, procedures and programs

2

What is CPTED?

Second Generation CPTED • No standard measurement tool • Analysis structure unique to each site

• Based on site context

3

Why CPTED?

Violence in the workplace

3

Why CPTED?

Violence in the workplace

Canadian Centre for Occupational Health and Safety

3

Why CPTED?

Hospital work can be surprisingly dangerous

3

Why CPTED?

Injuries come at a high cost Example of costs associated with Hospital Worker injuries

3

Why CPTED?

Recent Canadian Examples

3

Why CPTED?


3

Why CPTED?


3

Why CPTED?


3

Why CPTED?


4

Methodology

Facility/Site Tours Determine scope of review • Priority areas (i.e. ED, exterior site) • Time of Day (i.e. lighting) • Season (i.e. snow coverage)

4

Methodology

Generic CPTED Audit Checklist

4

Methodology


4

Methodology


4

Methodology


4

Methodology


4

Methodology


4

Methodology

Photos Good photos are critical for CPTED reports • Improves understanding of CPTED concepts • Assists in analysis • Critical when a site visit is not possible

4

Methodology

User Engagement • •

Obtain “behind the scenes” data Creates the base for development of second generation CPTED analysis

4

Methodology

Site-specific data • • •

Incident reports Existing policies, procedures, programs Context (cultural, environmental, etc.)

4

Methodology

Floor Plan Analysis Provides inventory of current state CPTED condition

4

Methodology

CPTED Report Sample table of contents

5

1st Generation CPTED

• Specific examples • Previous CPTED reviews • Existing conditions and recommendations • Based on Stantec-developed methodology

5


Lighting From a security point of view, lighting that is strategically placed can have a substantial impact on reducing the fear of crime (National Crime Prevention Council). • Illuminate vulnerable spaces • Discourage potential criminal activity (fear of being seen) • Lighting can act as an invitation for the use of space (illuminating areas that are not intended for use can encourage undesirable gathering/activity) Natural Access Control


Territoriality

Maintenance

5

st 1

Generation CPTED

Lighting Current State: There were several sharp corners along the facility where no lighting was provided.

Recommendation: •

Lighting should cover blind spots and potential hiding places near entry points

•

Automatic overhead lighting should be provided

5


Lighting Current State: The lattice patterned screen over the lighting in the nursing station removes harsh lighting and glare and provides for a calm working environment.

Recommendation: • Provide calming features in staff work environments that are subject to tension and stress

5

st 1

Generation CPTED

Lighting Current State: The lighting for the emergency department waiting area is very bright and centrally focused on the seating. Recommendation: • • •

Bright glare lighting should be reduced Adding a screen over existing lighting Replacing existing lighting with peripherally placed fixtures

5

st 1

Generation CPTED

Signage Well designed and strategically placed signage can contribute to a feeling of security (National Crime Prevention Council), by minimizing disorientation and increasing a person’s sense of direction on the site. Signage should: • Be legible (appropriate size, colors, etc.) • Be strategically located • Include adequate information for its use. • Be regularly maintained, as damage or vandalism could significantly hinder a signs purpose. Natural Access Control


Territoriality

Maintenance

5

st 1

Generation CPTED

Signage Current State: Some of the signage in the ED department is out of date and could cause confusion for patients/visitors.

Recommendation:

•

Obsolete/incorrect signage should be replaced or removed

•

Reduce the risk of irritability and frustration

5

st 1

Generation CPTED

Signage

Current State: View of detailed wayfinding maps near the main entrance are obstructed by the storage of hospital equipment. Recommendation: •

Way-finding signage should be large, legible, identifiable and should use strong colors, standard symbols, simple shapes and graphics (National Crime Prevention Council)

•

Signage should be barrier-free

5

st 1

Generation CPTED

Sightlines A clear sightline is defined as an unobstructed, desired line of vision in both terms of breadth and depth (National Crime Prevention Council). Clear sightlines can reinforce the classic concept of Jane Jacobs’s Eyes on the Street concept, which suggests that the more people viewing a particular space, the safer that space becomes.

Natural surveillance can be achieved by removing obstructions to sightlines such as solid walls/fences, overgrown landscaping, or any other barriers found within the built environment. Natural Access Control


Territoriality

Maintenance

5

st 1

Generation CPTED

Sightlines Current State: Many door windows throughout the facility were blocked with signage, reducing sightlines into the corridors and limiting natural surveillance within the area. Recommendation: •

Window signage should be relocated

•

Blinds should remain open where possible

•

Provision of bulletin boards could be considered

5

st 1

Generation CPTED

Sightlines Current State: The high partition of workstations located at the entrance of the main lab space causes a break in sightlines throughout the space.

Recommendation:

•

Shelving units and staff workstations should be lowered to a height no larger than 1 metre

•

Additional dome mirrors could be installed

5

st 1

Generation CPTED

Isolation Isolated areas are places where people feel insecure, as they out of sight and sound, and subject to minimal natural surveillance due to low levels of activity within the space. Where possible, natural surveillance should be increased for isolated areas, by encouraging more human presence within the space and by manipulating surrounding materials to permit visual penetration from surrounding spaces(such as use of glass, materials with cut outs, etc.). However, there are some cases where increasing natural surveillance is not possible; these isolated spaces are best mitigated through the use of surveillance capacities, such as security cameras and employing security guards.



Territoriality

Maintenance

5

st 1

Generation CPTED

Isolation Current State: The kitchen is isolated off the patient lounge with no windows on either of the two entry doors. Some of the blinds in the kitchen are stuck in down position and further isolates the room.

Recommendation:

•

Both doorways into the kitchen could include windows

•

Blinds should be repaired to allow for natural lighting

5

st 1

Generation CPTED

Isolation Current State: Public washrooms are located in an isolated corner adjacent to the main entrance, and is accessible by people entering through the ED during after-hours. Recommendation: •

A security camera with associated signage could be installed

•

Doors to the washrooms could swing both ways to prevent the barricading of the door from the inside

5

st 1

Generation CPTED

Escape Routes/Movement Predictors Movement predictors relate to the ability to predict the movement of a person either to or from an area and escape routes refer to the exiting and entering of people within the space. There are different instances regarding security and escape routes: • Facility Escape Routes: Multiple escape routes should be provided to users of a space in the event of emergencies, such as a fire. Several options for access/egress also decrease the ability for offenders to predict a person’s movement. • Second means of egress from a space: A second exit should be provided for all spaces where mental health patients may be seen. • Access Control: An abundance of escape routes from a site can act in favor of an offender, as they have several options to disappear resulting in a limited ability to predict their whereabouts. The limitation of escape routes can deter offenders as criminal activities become too risky (Atlas), resulting in their movement becoming more predictable. Access control can include informal/natural (spatial definition), formal/organized (security personnel) and mechanical (locks and bolts) strategies (Cozens, Saville & Hillier). This restricted access strategy is also termed “target hardening” in some CPTED interpretations. Natural Access Control


Territoriality

Maintenance

5

st 1

Generation CPTED

Escape Routes/Movement Predictors Current State: A flip counter at triage is easy to lift up, providing easy access into the ED. Metal sliding curtain is difficult to slide and is not used. Staff also move through the flip counter. Recommendation: •

Triage counter should be fixed and heightened with a solid base to discourage movement over or under

•

Triage room should be controlled with two points of entry/exit (sliding metal curtain should be replaced with a more functional system)

5

st 1

Generation CPTED

Escape Routes/Movement Predictors Current State: The clinical coordinator and physician offices (Psych Unit) each only have one access point. Patients are seen in the physician office.

Recommendation:

•

Offices that see patients should be equipped with duress alarms

•

Offices should have doors that swing into the corridor to prevent the entry from being barricaded

•

These offices should also provide a second exit

5

st 1

Generation CPTED

Activity Uses This concept suggests that mixed uses should be compatible with each other, in order to encourage activity, natural surveillance and contact among people throughout the day. The main uses of adjacent spaces should be assessed, as well as their hours of operation to determine what the levels of natural surveillance will be during day and night time hours. As redefining adjacent land uses is deeply rooted in both policy and built infrastructure, should it be determined that adjacent land uses are incompatible other mitigation strategies will be encouraged. Improving other CPTED concepts within a site such as, but not limited to, signage, territorial definition, and appropriate surveillance capacity can significantly increase adjacent use compatibility. Ibid. Natural Access Control


Territoriality

Maintenance

5

st 1

Generation CPTED

Activity Uses Current State: There are some dedicated staff functions, such as the code white button, that are located in the open corridor that patients have easy access to.

Recommendation: •

Code white button should be either moved to a designated staff-only area or should be enclosed with casing that requires controlled access

5

st 1

Generation CPTED

Activity Uses Current State: There is a children’s playground located directly adjacent to the loading dock area.

Recommendation: •

Relocate the playground at the front of the facility, near windows for natural surveillance

•

Add entry/exit points to the playground to act as boundaries

5

st 1

Generation CPTED

Maintenance Properties should be well maintained to create a perception of ownership and safety (National Crime Prevention Council). When a vandalized or damaged property is left unattended, it can encourage more destruction of that space by sending the message that these types of offences are acceptable. The Broken Window theory states that maintaining an environment to prevent small crimes such as vandalism, can help create an atmosphere of lawfulness, which in turn can potentially prevent more serious crimes from taking place (Wilson and Kelling).

Materials used in an environment can also affect certain safety features of the area. Examples include the use of glass and increased use of windows to encourage natural surveillance, and the use of lighter colors to prevent dark, shadowed areas.



Territoriality

Maintenance

5

st 1

Generation CPTED

Maintenance Current State: : There is a Spider Alert System installed on the unit, however the system is currently not operating. This system’s infrastructure causes paranoia among patients as they think it is a security camera.

Recommendation: •

Remove obsolete infrastructure

5

st 1

Generation CPTED

Territorial Definition Territorial reinforcement is the use of buildings, fences, signs, pavement, or other objects to express ownership or to clearly delineate the transition from public to private space (Oakland Police Department). The reinforcement of ownership among users of a space can also increase stewardship, where users become actively engaged in managing and caring for that particular area. Clearly defining the intended use of a space can help deter unwanted activity and attract desired uses. Natural Access Control


Territoriality

Maintenance

5

st 1

Generation CPTED

Territorial Definition Current State: : There are several instances within the DI unit where doors are propped open for staff efficiencies. These propped doors provide opportunities for people to enter the unit unannounced.

Recommendation: •

All doorstops could be removed, including both the unattached models as well as the models attached to the doors

6

2nd Generation CPTED

Incident Analysis Current State: • • •

Code White reporting Incident Reporting (site-specific methods) Reporting Issues

Recommendation: • • •

Setting targets Incident de-briefing Workplace education and training regarding safe reporting practices

6

2nd Generation CPTED

Hospital Policies and Procedures Current State: • •

Lack of role clarity throughout hospital policies Contractor (security services) not included in hospital policies

Recommendation: • Define first-responder versus second responder actions • All staff working in healthcare environments are working on the same team; ensure policies define roles for all potential responders • Ensure all potential responders are aware of policies

7

Implementation

• Design/pre-construction phases • Renovations/re-development

7

Implementation

7

Implementation

Staff presentations Example: Quick Wins

More Complex Modifications

Subtle barriers or signage Areas for staff only should not should clearly distinguish staff- only be labelled and closed, but only work spaces should also be equipped with hardware such as key or card access Doorstops may be removed where appropriate

7

Implementation

Policy updating • Management level Examples • Standardized reporting, electronic • Combined in-house security team with contracted services

Questions?

Bibliography Atlas, R.I. (2013). 21st Century Security and CPTED: Designing for Critical Infrastructure Protection and Crime Prevention, Second Edition. CRC Press: Boca Raton, FL. Cozens, P.M., Saville, G. and Hillier, D. (2005). Crime prevention through environmental design (CPTED): a review and modern bibliography. Griffin, J. (2013). Bolstering ER security through environmental design. Retrieved 15 March, 2015 from http://www.securityinfowatch.com/article/10947617/security-experts-discusscpted-considerations-for-hospital-emergency-departments

National Crime Prevention Council (2003). Crime Prevention Through Environmental Design: Guidebook. Retrieved 26 February, 2015 from http://www.ncpc.gov.sg/images/media/CPTED.pdf Wilson, J. Q. and Kelling, G.L. (1982). The police and neighborhood safety: Broken Windows. Retrieved 26 February, 2015 from http://www.manhattaninstitute.org/pdf/_atlantic_monthly-broken_windows.pdf