At nine stories tall and 386,000 square feet, the Big Lots Behavioral Health Pavilion at Nationwide Children’s Hospital opened in March in Columbus, Ohio, as the largest center dedicated to mental health on a pediatric medical campus in the United States. And while its presence and prominence were strategic, it’s the comprehensive programming the building supports that defines the endeavor.

In 2015, leaders at Nationwide Children’s began noting trends, not only in services its own patients were increasingly requiring, but also in national statistics—suicide among the leading causes of death in U.S. children, one-half of mental health challenges established by the age of 14. “When you look at those stats, you realize this is a huge problem in our country,” says Patty McClimon, chief strategy officer at Nationwide Children’s Hospital. “It was presenting to us in two ways. One was an influx of patients in our emergency room and our medical beds who required mental health care and, two, a feeling that these kids weren’t getting the right treatment.”

Nationwide Children’s set out on a quest to solve that, recognizing the necessity for both mental and physical health optimization in a comprehensive way—for example, the type of response frequently delivered for cancer patients but that’s been traditionally absent for mental health, McClimon says. “Typically, for a cancer diagnosis, you’ll see family support groups coming together and providing things like meal trains. But for a mental health diagnosis, that kind of support is absent. We hope that changes as we set out to break the stigma of mental health.”

And while the organization had an existing and robust outpatient behavioral health program, this new path led to a much less traditional solution: a large-scale building that would support a full continuum of care on its urban campus in downtown Columbus. That vision included space to accommodate everything from outpatient, inpatient, observation, short-stay, and residential services to prevention and research efforts to emergency and urgent care services, including a pediatric crisis stabilization department. A $50 million gift from Big Lots and Big Lots Foundation helped enable the vision to become a reality. NBBJ signed on as project design lead, with Architecture+ overseeing programming and intial block planning as well as providing mental health expertise.

Laying the groundwork
Several sites were initially considered for the building, including two others on campus as well as a more suburban location similar to most mental health settings, but ultimately the team felt this particular parcel on the main campus would best serve Nationwide Children’s in establishing its new hub as the center of its safety net of services, says Ryan Hullinger, partner at NBBJ (Columbus). Reasons included ease of access thanks to its location in the city as well as relationship to other departments on campus to take advantage of adjacent services including academic, administration, and research integration.

However, the tight urban site and extensive program would require building up as opposed to out—but it helped achieve something else, too. “Its largeness is an attribute that really does demarginalize and destigmatize mental health care and create a flagship for this kind of care that gives it the visual prominence on campus that it deserves. Its positioning, its size, and its shape were a big part of those [site] studies,” Hullinger says.

However, that didn’t mean the design team wasn’t challenged to make such a large building work on such a constrained space. Frank Pitts, principal of Architecture+ (Troy, N.Y.), says that traditional approaches to mental health—low-rise, residential scale—generally deliver a lot of small rooms that all have light and views and don’t “pack into small boxes particularly well,” requiring some creative thinking for this project to achieve the same amount of nature and daylight. “We were convinced the site was the right place to put it and collectively worked our butts off to find a form factor that allowed us to be there,” he says.

The solution was a basic podium building with a nursing tower built atop it, with an outdoor deck level planned at the middle of the podium as a void that the inpatient units (built to house 48 beds) could be wrapped around to achieve goals for light and views. The top of the podium allows for two large courtyards, while an additional rooftop gym and outdoor play deck as well as screened-in porches on each inpatient unit together answer needs for access to the outdoors. “All of those things were really about upending the conventional thinking about the shape and form of mental health care and doing it in a fundamentally different way that allowed us to work in this urban environment,” Hullinger says.

Intricate detailing
Beyond the site itself, an immense amount of research was conducted by Nationwide Children’s on the front end of the project, garnering knowledge of what other providers across the country were doing and conducting site visits. Additionally, the organization, which had opened its first behavioral health inpatient unit in 2014, recognized it had a wide range of knowledge available from its own staff, as well. To ensure that expertise was applied to the new building, the design team implemented an extensive mock-up process, including three patient room models that evolved from cardboard to drywall and finishes to ensure the details were right.

The specifics explored were as intricate as the joinery on millwork and casework to embed safety in the componentry—for example, concealing fasteners and hinges and the easing or rounding of edges and corners were important to the mitigation of self-harm risks, says Edwin Beltran, principal at NBBJ (Columbus). Durability and maintenance issues were considered, as well. “One example is making sure that patient beds were durable. To that end, our team studied and eventually specified a stacked plywood finish that, if scratched or dented, helps to visually camouflage the wear and tear. It is a very resilient solution,” Beltran says.

Flooring, too, was addressed, with a sheet flooring product chosen that allowed the team to continue the design language found in other buildings on campus but was installed using a seaming strategy that enables repairs within hours and without shutting down a unit—a priority for the project. Even the wall base was carefully analyzed to ensure it couldn’t be torn off or create a sharp edge that might physically harm someone.

Another element weighed in the mock-up phase was corridor width. Simulations that considered the scenario of patients lashing out or potentially hurting themselves found that a traditional 6-foot hallway was dangerous because someone could be thrown against the wall, whereas an 8-foot width allowed enough clearance to avoid that—even if more costly, McClimon says. “Adding those two extra feet was really important to staff safety,” she says.

As staff as well as family members, program graduates, and community members toured the mock-ups to further refine the design, “we quickly realized we had a lot of safety issues dealt with, and the tweaking of the mock-ups really went to look and feel,” says Ed Cheshire, senior project manager in engineering at Nationwide Children’s. “We knew what would impact behavior. So how do you make a space really welcoming, engaging, and comfortable?” One way the design team worked to answer that was by moving away from corrections-based safety products to achieve a sense of normalcy in furniture and finishes. “I think it’s a point of view or a cast of mind, that you walk into it thinking safety—but with every time you say ‘safety’ you also say ‘normative, familiar, fun’ and you try to have those qualities also be part of the safety,” Pitts says.

Innovative lighting systems were used, as well, including in the inpatient bathrooms. “These bring a touch of supportive normalcy and dignity through flattering lighting helping to boost the self-image of adolescents dealing with self-esteem issues,” Beltran says. Additionally, “in the inpatient rooms, color-changing ambient lighting fixtures provide a therapeutic positive distraction intended to reduce anxiety and de-escalate aggressive behaviors. Touch-activated reading light sconces add a safe, domestic touch to the room and give patients another element of control over their environment.”

To further support the effort and make decisions that would work across the spectrum of the facility, a design toolkit was developed to identify a set of complementary furniture pieces that worked well as a whole while also addressing the variety of functional needs throughout the building, Beltran says. “For example, within our furniture selections, there were pieces that offered hard versus soft molded options, heavy-weighted versus light-weighted options, and safe additive assemblies versus monolithic construction. The thinking around having such a set of complementary options was to ensure that if in the future a specific product was deemed not appropriate for a particular care unit because it was too hard or too heavy, it could be replaced with a softer and lighter product that was already part of the toolkit and wouldn’t compromise the aesthetic unity of the project.”

Finally, yet another challenge was approaching the delineation of spaces across the massive program housed within the pavilion that serves kids ages 3 to 18 from diagnoses and treatment across an array of care settings and care models. To manage that inherent complexity, the team took a closer look at the differences between outpatient and inpatient care, specifically, conducting a risk assessment that led design decisions in terms of the “what, where, and how” of every decision impacting material usage within the patient environment, Pitts says. “We ended up with a gradient moving from less emphasis on self-harm in the outpatient environment and much more emphasis within the crisis, residential, and inpatient environments, but always also guided by sections that were both safe and noninstitutional.” The process also helped Nationwide Children’s target exactly where it was necessary to spend money on upgrading safety, Cheshire adds. “That really helped us afford the building,” he says.

Although it was a delicate balance to answer desires for safety, durability, and noninstitutional design, Cheshire says the environment achieved was the result of a mindset that considered the 90-95 percent of kids who will be treated at the pavilion and who won’t exhibit aggressive or dangerous behavior as opposed to the 5-10 percent who will. “If we have a child who we know may be really destructive, really harmful to the environment, maybe we need to think differently about how we care for that child, what the staff ratio is, and not let the worst-case scenario rule the design process,” he says.

Experience and safety
Experience—for patients, family, and staff—was a key project imperative, as well, especially understanding how underlying elements of safety play a role in developing experience. The process began with a recognition of the brand already created at Nationwide Children’s and figuring out how to translate that to the behavioral health setting. “We agreed early on that it had to feel like a sibling to the inpatient tower,” Beltran says of the relationship between the behavioral health pavilion and the main hospital. “Wayfinding, graphics, colors are all part of the family.” The approach (PlanIt Studios of Worthington, Ohio, assisted in the design) includes a continuation of an environmental graphics program with a nature theme, featuring animal friends as a positive distraction—all repeated but in a manner that’s safe and appropriate for the behavioral health environment. “It’s not something that can be pulled away from the wall or that patients could use to harm themselves. It was all accomplished with paint,” Beltran says.

To involve families in the treatment process on a deep level, every patient room includes a parent bed, an integrated component in front of the window, to accommodate overnight stays.“[The family-friendly approach] extends to the lounges that are on every floor between the two units to a siblings room on the ground floor to an information-sharing space—it’s really an extension of Nationwide Children’s commitment to taking care of families as well as taking care of the child,” Pitts says.

Staff are thoroughly supported in the pavilion, as well, with a dedicated outdoor courtyard for respite, inpatient break room that’s the “corner office” on the units, and a comfort room where clinicians can relax after an incident and speak with a counselor, Cheshire says. Operationally, there are no nurses’ stations on the inpatient units, known as neighborhoods—instead, the organization chose to create a windowless caregiver office in the heart of the units where staff can go to take notes, make calls, etc., and then return to patients.

Also contributing to the experience is an onstage/offstage organization that was brought over from Nationwide Children’s other facilities—another approach that isn’t traditionally translated to mental health projects, Pitts notes, but effectively keeps operational components out of sight from patients and families. “It makes a difference in terms of those inpatient units and how they’re operationalized and how they’re experienced,” he says. “That’s a huge learning for me.”

The hope for the environment that exists today—including the wide corridors, graphics on the walls, and durable finishes that can’t be weaponized—is that it will promote the well-being of staff and, in turn, have a positive effect on care delivery. “The building becomes an instrument that amplifies the agency of the caregivers; it’s part of their toolkit for providing therapy,” says Hullinger. “When they need to be supportive, the building helps them be supportive. When they need to be protective, the building helps them be protective. And when the caregivers need to be inspiring, the building helps them inspire. … All of that contributes to an enhanced psychological state for the staff that helps them provide their best possible care.”

Home run
After the $159 million pavilion’s completion, Nationwide Children’s hosted what McClimon calls “96 hours of fun” filled with facility tours, a donor dinner, and a summit for behavioral health providers from 60 children’s hospitals across the country. The events together allowed the staff to share what they’d accomplished with the new building and understand how it can inform others. “That made our team super proud, and we recognized that what we’ve done is unique across the country,” she says.

The days’ events also allowed the provider to capture how meaningful the effort would be for its own families at home in Columbus, as parents of children who had gone through the program—some graduating and others losing their children—offered insight on what it feels like to walk through those doors after a traumatic experience at home. “Thinking about buildings in that perspective, how do you take care of those families who are hurting and are in need? That really took it to a different place for Nationwide Children’s,” Cheshire says.

Jennifer Kovacs Silvis is editor-in-chief of Healthcare Design. She can be reached at