Healthcare Security’s Evolving Built Environment

The healthcare-built environment has gone through dramatic alterations over the past few years. From lockdown to perpetual facility manipulation, physical building structures like doors and hallways to HVAC systems, electrical and IT systems, and of course security systems. Many lessons were learned, and processes modified to deal with the quickly changing environment. For security, the challenges over the past few years have been mainly access control and increases in violence. Maintaining access control by securing building entrances so patients, visitors and staff could be funneling into one designated entrance for temperature and access screening. Dealing with violence incidents caused by mental health and frustration due to the pandemic.

The healthcare security condition has dramatically changed over the past few years identifying security weaknesses and strengths within the built environment. Lessons learned show that going forward the security-built environment must change, so that as a profession we can better control sudden changing environments while dealing with the problems at hand. Changing the built environment can dramatically reduce the opportunity for crime and violence while positioning the security department to better handle the next major adverse event.  

What needs to change in the healthcare security-built environment? Hospitals need to alter the physical environment to reduce the potential for violence and crime within its facilities. In the evaluation of the built environment, security professionals should be involved in the design of renovated or construction development stages, not be involved after the design has been finalized or when construction has begun.

Providing appropriate security for a given healthcare facility starts with the manipulation of the physical environment, not just the installation of technology that may or may not be engineered out of the project budget. The physical design of a facility drastically reduces the potential for crime and violence providing appropriate access control, surveillance, notification, and response. Each area of the hospital or medical facility must be designed in a specific way that provides appropriate security measures adequate for the protection of staff, visitors and patients that reside within that specific area.

For the safety of hospital staff, hospitals should be built like hotels having a “back of the house.” This means that hospital services are separated from clinical services, not seen by patients or visitors, and restricting access into the back of the house. One side of the hospital on all floors should contain support services and staff functions like locker rooms, bathrooms, offices, storerooms, along with all support services. The other side of the house should be clinical services like patient rooms, exam rooms, doctor’s offices, and other clinical functions. Access into the support services side of the hospital should be restricted from the clinical services side. Surveillance capacity on the support services side should allow for the natural surveillance along with electronic surveillance of the access-controlled doors so that staff can quickly identify unauthorized individuals entering the support services side of the hospital and intercept them before they wander too far.

Hospital entrances should be segregated as well. There should be a separate employee entrance for employees, vendors, and contractors. This area should be staffed so that appropriate credentialing can be completed for staff and others entering the hospital. For clinical entrances, when possible, entrances should be created for specific services, like Maternity or Pediatrics. At entry points persons entering should be screened so that they can be properly directed to the appropriate location.

Parking facilities should only allow access to the main lobby. If elevators are being used, then the elevators should only service the garage or parking lots, not the upper floors or clinical areas.  

Non-medical areas like offices retail spaces, Medical Records pick-up, finance departments, Cashier, Human Resources, to name a few, should be located off site from the main hospital and other clinical spaces. The advantage of removing these services from the main hospital is that it dramatically reduces the opportunity for unauthorized persons to gain access into the main hospital. Ancillary services like the chapel, café, and bathrooms should be located on the ground floor off the main lobby and in front of security check points. The purpose of this design is to create a non-secure area allowing anyone to enter the hospital but restricting them from accessing patient care areas.

Clinics and other out-patient services need to be removed from the main in-patient hospital. This eliminates the potential for unwanted patients, visitors, or unauthorized persons from accessing the main hospital. All out-patient service areas that provide a waiting room or have patients waiting for services should have a physical barrier separating the waiting area from the clinical space. Doors that access the clinical space should be closed and locked. Patients should be either escorted into the clinical area or be electronically buzzed into the area. Physical separation eliminates the potential for unwanted patients and visitors to have access into clinical areas. Reception staff should be equipped with duress buttons and have an alternate means of egress away from the waiting area, a safe haven, if violence should erupt.

 In the built environment for security, the physical layout and structure of the Pediatric and Maternity units is paramount in the safeguarding of infants, children, and parents. The physical layout for these areas should provide controlled access and surveillance capacity for the entire unit. That means positioning the nursing unit strategically to provide the best natural surveillance to entrances and exits. Enhancing surveillance capacity by installing cameras recording at a high frame rate, so that recorded video has a clear well-defined picture in the event of an adverse event. Access into and, if possible, out of the unit should be controlled by staff so that unauthorized persons cannot enter the unit unless properly screened.

For Surgical Services the high-risk areas are the PACU and the Operating Rooms. For the PACU the nurse’s station should be close to the entrance and should be able to view the entire PACU with no hidden areas. Access into the PACU and the Operating Room should be restricted. Surveillance capacity should include high risk areas such as equipment and supply storerooms and drug storage areas. The PACU and Operating Rooms should be located in an area of the hospital that is not close to main public areas like the lobby or general medicine units, reducing the potential for wandering patients, visitors, and unauthorized persons from accessing the department.

Visitor waiting areas for both these units should be located at a distance from the PACU and the Operating Rooms. These areas should be surveilled so that disruptive behavior can be quickly identified. If hospital staff is stationed in the waiting area, a duress alarm should be installed for the staff in the event of an adverse event.

For ICUs access control as well as surveillance capacity is important. Because of the potential for high-risk patients, the unit should have the ability to lockdown, controlling access via an intercom and card reader for staff. Visitors should be screened before entering the unit and the ICU waiting area should have surveillance capacity so that potential problems can be identified before they escalate. Many hospitals control access into their ICUs all the time while others only activate access control measure when a high-risk patient is present.

Emergency departments should have restricted access from all entry points, limited to only essential personnel. There should be a physical barrier separating waiting patients and visitors from treatment areas. Support staff like registrar and triage should have spaces that access the waiting area but be housed within the clinical space. These staff members should have access to a safe space in the event of an adverse event and have a physical barrier yet personable space between them and patients. Visitors should be restricted from treatment areas unless for necessity, like translation or serious illness.