Hospitals exist to heal and restore health, but that can be difficult to accomplish if building users don’t feel safe. In fact, a safe environment is a major contributor to healing, yet violence in hospital settings is on the rise. In 2017, the U.S. Bureau of Labor Statistics found that of the 18,400 nonfatal intentional workplace injuries reported, 71 percent occurred in the healthcare and social services sector.

Each day, hospitals face both internal and external threats including active shooters, domestic violence, terrorism, gang violence, behavioral health-related incidents, theft, workplace violence, and abductions. In a recent interview with Crain’s Cleveland Business, Dr. Tom Mihaljevic, president and CEO of Cleveland Clinic, called hospital violence an epidemic, saying his system confiscated more than 30,000 weapons during 2018.

While these are the unfortunate realities hospitals must be prepared to face, creating a complex situation for administrators and caregivers, there’s an opportunity for hospitals to increase safety through intentional and comprehensive design and facility planning.

From outside in

Visibility is a critical element to ensure safety and the quick response of staff and security in the presence of a threat. When it comes to exterior spaces, perimeter landscaping should not impede visibility and parking garages should be well lit and allow for full camera coverage. Positioning of buildings on the site should take into account vehicle standoff distances, or the amount of space required between buildings and driveways and parking areas to protect from vehicle-borne explosives. Other vehicle barriers such as bollards, concrete security planters, reinforced furniture, water, and berms should be incorporated into site design to further protect buildings and outdoor gathering spaces. Additionally, highly visible emergency call boxes should be located strategically around campuses for emergency communications.

Next, external and internal perimeters should define zones for patients, visitors, and healthcare staff. Monitored entrances that utilize badge access are critical to prevent the public from accessing unauthorized back-of-house areas. Visible security staff, visitor/vendor badge systems, and even metal detectors should also be considered.

Once inside, compartmentalizing a facility will help limit the threat of an active shooter by reducing the shooter’s ability to move freely, providing greater safety and escape opportunities for patients and staff.  This can be achieved through the use of physical barriers, access control, and rapidly closing cross-corridor doors that are integrated with security system panic buttons. Designs should also include multiple areas of refuge to shelter in place with no visibility from corridors. If possible, these shelter-in-place locations should be securable, windowless rooms with concrete walls. Add-on barricade options to prevent forced entry have been utilized in many school systems and should be considered in a hospital’s review with local code officials.

Design strategies

While risk reduction is a multifaceted issue, attentive design is the first line of defense against potential hospital security threats. The following strategies may be implemented by hospitals to create a safer healing environment through design:

  1. Holistic design. It’s important to integrate the owner’s security team with the project team at the onset of master planning and programming to help ensure vision and needs are captured. A holistic approach to security design should consider the physical, electronic, and operational elements that integrate technologies with physical barriers, structural resiliency, strategic lighting, and incident command centers to address today’s hospital security risks.
  2. Risk assessment. Evaluate the facility’s existing issues by conducting a risk assessment to test system resiliency. This should be done with a comprehensive technical and operational team composed of architects, engineers, security personnel, clinicians, and IT staff. Using mock scenarios (domestic violence, abductions, active shooter, theft, cyber-attack, etc.), this team should evaluate facility security weaknesses, particularly the impact that threats may have on high-risk areas such as the pharmacy, emergency department, labor and delivery, loading docks, and the building perimeter. Once risk has been assessed, the team will make recommendations and develop corrective action plans to address potential security breaches and areas of concern. It’s recommended that hospital administrators collaborate with local law enforcement during design to create security command center and overall emergency response plans.
  3. Security technologies. Project teams should consider current and developing technologies that can help reduce risks. For example, virtual fencing uses security cameras and video analytics to define a “fenced area” and send an alert to security to investigate when an unauthorized individual has breached a zone. Additional technologies, from visitor management systems to access control to emergency notification and duress systems, are designed to allow security personnel to minimize risks and respond swiftly to potential threats.
  4. Education and training. The International Association of Healthcare Security & Safety and the Occupational Safety and Health Administration offer hospital safety guidelines that should be considered for implementation into facility operations and building design. Ongoing security education, protocols, and technology user training are extremely important. Regular training drills should be utilized to keep hospital staff prepared to implement emergency-response plans with technologies implemented.

Next steps

If hospitals are to be conduits of healing, the safety of patients and hospital employees is essential. Administrators looking for ways to address today’s increasing security threats should start with a holistic risk assessment using a comprehensive team that can integrate the operational, technical, and physical building elements needed. Armed with these results, administrators can begin to make the security adjustments needed in existing facilities, master plans, and new projects to ensure that the hospital can accomplish its mission of health.

Ted Hood is senior project manager at TLC Engineering Solutions (Brentwood, Tenn.). He can be reached at David Stewart is a principal and healthcare studio leader at Orcutt/Winslow (Nashville, Tenn.). He can be reached at