Gregory S. Knoop, AIA, LEED AP & Aphrodite Knoop, WELL-AP, LEED Green Associate
Katrina, Sandy, Maria, and Harvey… Such innocent sounding names for disastrous super storms that destroyed lives and property and revealed a tragic lack of resilience in the very structures that should have been at the front lines of community response and recovery: healthcare facilities.
Consider that during Hurricane Katrina in 2005, numerous hospitals in New Orleans were either closed or damaged. Memorial Medical had 45 patient deaths from the storm due to lack of preparedness. When Hurricane Sandy struck New York and New Jersey in 2012, 6,300 patients were forced to evacuate from 37 healthcare facilities, as reported by the American College of Emergency Physicians. This evacuation was coined “patient surge” by physicians writing in the Annals of Emergency Medicine. And, “…some facilities received large numbers of patients with no advance notice, and others prepared to receive patients who instead went to other facilities,” according to Healthcare Finance.[i]
Since Hurricane Sandy, “resilience” has emerged as a key issue in healthcare design.[ii] However, a resilient building is not necessarily a green building. That’s an important distinction because resilient design is about survival and recovery, whereas green design is about environmental and wellness best practices.
So, what is resilience really? Quite simply, it is the capacity of a system to recover from disruptive events and return to a prior state or trajectory. It applies to facilities, redundancies, reliabilities, processes, management, and economics. In the built environment, resilience relates to how facilities are able to recover or be part of the overall recovery for the communities in which they are located. For example, for data centers, there is the Up-Time standard that addresses the reliability of facilities to provide continuous operations.
While there is no such standard for hospitals outside of the codes, in their communities, hospitals play such a critical role for recovery from extreme weather, terrorist attacks, or other disruptions, that they too must have resiliency planning and strategies to reduce the risk of downtime and loss of life.
The Resilient Healthcare Facility
As well as requiring their own resilience to meet basic mission goals, healthcare facilities are part of the broader system of community resilience. Key in the way these facilities play a role is in emergency health services, disaster recovery, social equality, and economic fortitude. Hospitals and clinics are an important part of the strength of communities, playing a critical role in promoting human health, providing quality jobs over a broad range of skill sets, and in supporting the economic well-being of a community. Planning these facilities with resilience in mind, as well as adapting older facilities to present and future norms is crucial in making our communities capable of providing services under the worst conditions.
Unfortunately, hospital systems often are reluctant to upgrade their aging facilities due to high costs and competing priorities, leaving them vulnerable to disaster, according to a 2012 survey by Insurance Journal. [iii]
A 2018 report sponsored by the Center for Health Security and the Johns Hopkins Bloomberg School of Public Health concurs that disaster planning in U.S. healthcare is decades old, leaving facilities ill-prepared for large-scale disasters. The report further notes that other sectors that support or interact with the healthcare system and are needed for creating disaster-resilient communities are inadequately prepared for disasters.[iv]
To mitigate some of the costs, insurance companies should be the first to provide incentive benefits for facilities and organizations that are taking progressive steps toward creating more resilience in their operations and facilities. When we are talking about a facility or company with a massive insurance policy, that is an important customer, carrying a large policy on many fronts. A facility taking resilience planning actions is creating risk reduction and should therefore share the benefits between insurer and customer.
There have been significant steps in this direction. For example, the 2015 National Institute of Building Sciences (NIBS) white paper, Developing Pre-Disaster Resilience Based on Public and Private Incentivization, developed in conjunction with the Council on Finance, Insurance and Real Estate, “…identifies the potential mechanisms from both the public and private sectors that can drive investment in mitigation—an approach called ‘incentivization.’ This expanded assessment of opportunities to encourage mitigation investments identifies mechanisms outside those currently offered by government programs.”[v]
Elements of Resilience Planning
In addition to policy and insurance measures, design plays a key role in resilience planning. The following are among key considerations:
Location, location, location: Location is one of the most important issues for addressing responsiveness and reliability. For example, a hospital should be intelligently placed in a highly accessible area, serviced by a broad range of transportation and transit access. Healthcare facilities should be away from potential natural hazards that could leave them vulnerable to critical failure when they are needed most. Such areas include swamps and flood zones.
Design of the facility: Planning should reflect an open architecture that permits growth and maturity of facilities and services to address a community’s needs. The planning and design team should work hand-in-hand with the community to provide the needed services. The Certificate of Need (CoN) process, followed by many jurisdictions, is an appropriate way for creating a balanced and responsive scaling of healthcare providers to the community; which also is key in a community’s planning for resilience.
Transportation: There must be uninterrupted access of patients, staff, first responders, suppliers and more. Regarding transit, easy access is both part of smart planning and social equity. Our transit systems play a key role in connecting communities to important facilities like hospitals and clinics.
Utilities: Healthcare designers and planners should aim to follow the trends of modern smart cities, providing state-of-the-art utilities for energy, water, sewer, and communication.
Life safety: There must be development of a 99.9999% fail-safe life safety system within the hospital as well as access of first responders to the hospital.
Resilience planning applied to the built environment draws on expertise in that industry to create strategic methodologies for buildings, campuses, and municipalities. The processes require the establishment of a definition of disruptive events and the risks assigned to them, the organization of systems that contribute to elasticity, the requirements of those systems, and the prioritization of system recovery timelines to support overall resilience. The framework of the methodology we recommend entails the following steps:
- Research and information gathering
- Risk analysis and prioritization matrix
- Functional requirements development
- Strategic resilience plan and budgeting framework
- Operations, readiness, and training framework
Teams must include architects, planners, engineers, healthcare providers, policy makers, first responders, economists, and a number of other experts relevant to the scope of planning that is required.
The purpose of our built environment and of urban areas is to provide a common home for communities and for our collective support and well-being—particularly in the face of systemic stresses. Our healthcare facilities are a key element in the resilience of our communities and must themselves be resilient. And though resilience infrastructure may not be as appealing as state-of-the art surgical equipment for hospital administrators, emphasis on resilience will ensure a facility’s long-term viability, fiscal health, and critical supporting role in its community.