Resilient design in health care: Four steps for surviving a crisis
Learn the basic concepts and strategic planning needed to ensure resilient design of hospitals and health care facilities to reduce risk during natural disasters and man-made threats
- Understand what is at risk if health care resiliency is not considered during design.
- List the resilient design principles that allow communities to survive various threats.
- Learn a step-by-step process to address resilient design.
- Identify the value that the consulting engineer provides in resilient design.
Even before the COVID-19 pandemic, establishing the resilient design of health care institutions had already become increasingly critical and complex. Our radically changing world has introduced an array of threats, from the current pandemic to wildfires, floods, hurricanes and tornadoes.
The risk of storms has always existed, but the intensity of these storms may be increasing with the unnatural effects of human-caused global warming. Research shows that the trend will likely continue as long as the climate continues to warm. One only needs to consider the effects of some of the more destructive natural disasters to understand what is at risk in resilient design:
- In 2012, Hurricane Sandy caused problems for New York Universtiy Langone Medical Center in Manhattan, where flooding in the hospital’s basement destroyed four MRIs and other valuable equipment, washed through a lecture hall and library and knocked out emergency power. Estimated cleanup and recovery costs exceeded $700 million.
- A tornado in May 2011 ripped through St. John’s Regional Medical Center in Joplin, , blowing out nearly every window and collapsing some walls and the roof. A new hospital, Mercy Hospital Joplin, has been built as a replacement at a cost of $350 million.
- When the Mississippi River flooded in 2008, employees of Mercy Medical Center in Cedar Rapids, Iowa, scrambled to plug up toilets and sinks that were overflowing onto the ground floor. The water forced the hospital to close for 16 days and spend $68 million on cleanup.
Today, hospitals and health care facilities also need to plan their responses to other threats, like active shooters, cyberattacks and, as we are experiencing now, highly contagious disease outbreaks. With such a broad range of risks, how can hospitals ensure they are adequately prepared?
The first step in preparing for resiliency is to understand the characteristics of resilience itself.
What is resilient design?
Resilience, as defined by the Resilient Design Institute, is “the capacity to adapt to changing conditions and to maintain or regain functionality and vitality in the face of stress or disturbance. It is the capacity to bounce back after a disturbance or interruption.” Resilient design is the intentional design of structures in response to these vulnerabilities using practical solutions.
The Resilient Design Institute offers several resilient design principles that allow communities to survive and thrive in the face of climate change, natural disasters and other disruptions. These principles include:
- Resilience transcends scales. Strategies to address resilience apply to individual buildings, communities and larger regional and ecosystem scales. They also apply to different time scales from immediate to long-term.
- Resilient systems provide for basic human needs. These include potable water, sanitation, energy, livable conditions (temperature and humidity), lighting, safe air, occupant health and food.
- Diverse and redundant systems are inherently more resilient. More varied communities, ecosystems, economies and social networks are better able to respond to interruptions or change, making them inherently more resilient. While sometimes in conflict with efficiency and green building priorities, redundant systems for needs such as electricity, water and transportation improve resilience.
- Resilience anticipates interruptions and a dynamic future. Adaptation to a changing climate with higher temperatures, more intense storms, sea-level rise, flooding, drought and wildfire is a growing necessity. At the same time, nonclimate-related natural disasters, such as earthquakes, solar flares, terrorism and cyberterrorism, also call for resilient design.
- Resilience is not absolute. Recognize that incremental steps can be taken and that total resilience in the face of all situations is not possible. Implement what is feasible in the short term and work to achieve greater resilience in stages.
A step-by-step process to address resilient design
Using the previous principles, health care institutions can ensure that they are ready to survive a crisis. By implementing the following steps, engineers can effectively address resiliency in building design.
Step 1: Perform a risk assessment
Risk analysis is essential to informed decision-making and long-term planning. The first step in addressing resiliency is to complete a hazard assessment. Examine historical events, predict the potential for future events and determine how to deal with them. Use vulnerability assessment tools to evaluate the situation.
For example, Kaiser Permanente’s Hazard Vulnerability Analysis Tool provides a systematic approach to analyzing hazards that may affect demand for hospital services or a facility’s ability to provide those services. It helps to prioritize planning, mitigation, response and recovery activities. In addition to natural disasters like hurricanes, earthquakes and floods, look at other threats like a water or gas shortage, a communications breakdown or heating, ventilation and air conditioning failure. An all-hazards risk assessment for the hospital or health care facility should also consider the following areas:
- Mass casualty events: Health care resiliency is all about preparing the facility to deal with extreme circumstances, and that includes terrorism and active shooter situations. When a large-scale casualty event hits the community, the hospital will need to be prepared to contain the situation and minimize damage. Consider how the facility would respond if you reached capacity and were unable to service a large, critically injured population.
- Ask these key questions:
- Is the infrastructure available to rapidly expand our emergency department?
- How will additional emergency response vehicles be handled?
- How will family members and media be managed?
- Ask these key questions:
- Epidemics/pandemics: For many countries, the 2014–2016 Ebola outbreak in West Africa was a wake-up call regarding the importance of having resilient design of health systems. Similarly, fragile health systems across the world inadvertently contributed to disease transmission during recent epidemics of severe acute respiratory syndrome and Middle East respiratory syndrome. The current threat, COVID-19, is the latest outbreak with a whopping 15 million confirmed cases globally as of mid-July. When you discover a patient has a highly infectious disease, you need to act quickly to ensure the least amount of exposure. This is why you need a permanent or temporary quarantine space as well as a clearly established protocol that all relevant staff are aware of and have adequate training to execute. Also consider where to put the quarantine space in relation to the HVAC system to maintain the right pressure for sterility. Ultimately, how the hospital reacts in the minutes and hours after an epidemic begins can be the difference between lives saved and lives lost.
- Cybersecurity: Creating a secure information technology network in today’s world is more complicated than most health care facilities realize. The solution involves a wholistic approach to cybersecurity and cloud-based storage. Consider shifting the storage and processing of sensitive medical data to a third-party cloud provider; this allows electronic medical records and hospital servers to be protected by the cloud provider’s world-class experts in cybersecurity.
Step 2: Review building site design
Next, consider the location of the building. Is it in a geographical area that is susceptible to earthquakes or hurricanes? If it was identified as having a high risk in Step 1, take design steps to mitigate the risk, such as seismic design for earthquakes or envelope hardening for hurricanes. Consider the orientation and location of the facility and the community land-use policies surrounding the building.
For example, when Hurricane Ike pummeled Galveston, Texas, in 2008, the University of Texas Medical Branch was struck with winds exceeding 110 mph that pounded 100 buildings on the 85-acre medical complex and a 15-foot storm surge that flooded the lower level of every structure. After the water receded, the hospital conducted wind studies to ensure the new main entrance wouldn’t be in a wind tunnel and created major storm simulations to test potential exteriors by blasting mockups with water and wind.
Additionally, all exterior metal elements of the building were replaced with stainless steel or polyvinyl chloride, which are less prone to damage. To facilitate rapid cleanup after a high-water event, UTMB designers also made sure the walls on the first floor were water-resistant. Additionally, most elevator banks at UTMB are protected by flood gates that would move into position if needed, allowing the elevators to continue operating.
Step 3: Examine infrastructure
Examine the infrastructure’s level of hardening — which, in general, refers to the process of reinforcing individual systems within the hospital to make them more resilient against disaster. Consider not just the on-site generators but also the fuel supply, pumps, switching gear and distribution systems.
UTMB improved the resiliency of its infrastructure by moving vital elements out of harm’s way. All distribution for chilled and hot water runs on stanchions and the electrical and IT conduits run through beams on the roofs. All generators are either in buildings or on platforms 25 feet above ground.
Reducing energy consumption is another way to improve resiliency. The less energy a hospital requires, the longer its backup energy supply will last. Some jurisdictions place restrictions on the location of a generator. In addition, the amount and location of the generator fuel storage should be reviewed with local codes (sed Figure 2).
Step 4: Protect vital functions
Hospitals almost always stay open during a natural disaster, pandemic or mass casualty event to serve residents in need, and this can create a unique challenge for hospitals in areas prone to high water. At UTMB, the emergency department and other critical areas were above the ground level of the buildings so the hospital can continue operating even if the area floods again (the emergency department is now accessed via a ramp). Additionally, the HVAC systems were separated between the first and upper floors, so if the air below becomes tainted, it will not circulate into the upper floors.
It’s also important to plan for emergency routes into and out of the hospital. For example, during Hurricane Katrina, the staff at Tulane Medical Center in New Orleans had to improvise a helipad on the roof of their parking garage.
Resilient design investment
Making resilience a priority makes financial sense for a health care organization because prevention, in the form of mitigation, costs much less than the direct cost of repair and indirect cost of rebuilding the community around it.
According to the World Health Organization, the price for retrofitting nonstructural items costs as little as 1% of the value of a hospital, while possibly protecting up to 90% of the hospital’s assets. The Federal Emergency Management Agency also notes that the most common points of hospital failure from storms are the elevator machinery, windows and generators. Improving these assets often costs less than the cost to rebuild. Investments in energy efficiency also offer financial returns ranging from immediate to up to eight years. For health care organizations that own large building portfolios, even an eight-year payback (or 12.5% rate of return) can be viewed as cost-effective.
An emergency plan must apply to all types of anticipated situations, from a medical emergency to a hurricane or active shooter. To address this wide range of possibilities, hospitals should use a logical and repeatable process like a checklist of key considerations and corresponding action steps. To help avoid oversights when addressing smaller incidents, ensure that execution procedures do not vary, regardless of the scale of an event. Every emergency scenario should be handled with careful attention to prevent further disruption and damage. Ultimately, it is critical to develop and maintain training and testing programs and conduct drills that test the emergency plan.
True health care resiliency should be an ongoing process that is continually assessed and reviewed, alongside a consistent education and training program for hospital staff. While engineers cannot prepare for every harmful scenario, professionals can create a health care facility that is prepared to be resilient in the face of extreme challenges.
Ultimately, the purpose of resiliency is to allow facilities to care for the patient population regardless of circumstances — and when patient safety and hospital functionality are at stake, there is no room for cutting corners.
Those facilities that don’t prepare for resiliency run the risk of becoming a real-life example of WHO’s warning that “the most costly hospital is the one that fails.”