A Toolkit for Sustainable and Climate-Resilient Facilities

This Toolkit has been developed to assist organizations engaged in health care facility climate resilience as they improve their response to extreme weather events. The disruptions and losses incurred by the U.S. health care sector following recent extreme weather events demonstrate the need for specific guidance on ways to manage the new and evolving hazards presented by climate change. These events have also provided opportunities to learn from past disasters so that health care facilities, and the communities they serve, can be more resilient in the future.

By focusing specifically on improving health care infrastructure resilience, this Toolkit aims to assist organizations in reducing future vulnerabilities and losses, and improve the functioning of a broad range of health care facilities. The Toolkit is organized around five elements that illustrate specific health sector resilience principles and practices. Each element is accompanied by checklists and other resources that enable readers to further explore the topic. Case studies are included for each element of the framework.

The five-element framework does not directly address important additional considerations, such as institutional and administrative support for disaster- or emergency-preparedness efforts, education and training, and disaster response, recovery, and rebuilding. This framework and its accompanying checklists and resources should thus be integrated within a broader hospital and health care facility emergency preparedness enterprise; the framework itself should not replace current hazard vulnerability analysis tools and frameworks. By focusing specifically on health care infrastructure resilience, this five-element framework aims to help a broad range of health care facilities and organizations improve their ability to function in the face of climate change and extreme weather events.

Framework for Resilient Health Care Settings

Climate Risks and Community Vulnerability Assessment
Maintain up-to-date data on climate hazards and community climate and health vulnerabilities, and use hazard vulnerability analyses to inform health services and infrastructure planning today and for the future. Understand the role of the hospital, long term care and ambulatory settings within the community during and after identified extreme weather events, and use this knowledge to inform resilience strategies.

Land Use, Building Design, and Regulatory Context
Understand and catalog the land use, building design and regulatory context within which current health care facilities are situated. Are site improvements and existing building structures adequate to withstand extreme weather events now and in the future? What were the design assumptions for roads, stormwater quantities, building envelopes and structures, roof drainage systems? Consider the larger local and community land use vulnerabilities that may impact health care facilities in the face of extreme weather—aging or inadequately sized infrastructure or removal of natural buffers.

Infrastructure Protection and Resilience Planning
Construct critical health care facilities with sustainable communications, energy, water and waste infrastructure in appropriate locations to a standard of climate resilience to withstand events over the anticipated life of the structure. Infrastructure resilience measures reduced disruption, incapacitation or loss of use of critical health care facilities. For less critical facilities: design for safe closure prior to an event with the ability to resume services within 48 to 96 hours following a major event.

Essential Clinical Care Service Delivery Planning
Ensure that essential clinical care services remain operational during and immediately following extreme weather events. Often, hospitals must both shelter inpatients in place as well as handle patient care surges related to the weather event. Emergency departments, urgent care centers, laboratory and imaging services must remain operational. Nursing homes and residential care facilities house medically fragile, vulnerable populations. Research facilities house irreplaceable samples and data. In addition, health care settings may serve important non-traditional disaster response roles in their communities: sources for clean water, food, and shelter for a larger affected population.

Environmental Protection and Ecosystem Adaptations
Protect and support ecosystems and natural buffers to mitigate extreme weather hazards that may threaten your building or campus. Green infrastructure practices, heat island mitigation and enhanced stormwater management are key contributory strategies.  Understand that ecosystems, wildlife corridors, and natural hydrology patterns extend beyond individual property boundaries; engage the broader community in applying best design practices for adapting to extreme weather risks in order to mitigate future damages to property and people.

Checklists for Sustainable and Climate-Resilient Facilities

This Toolkit contains a set of introductory checklists for each of the five elements of climate resilience. These checklists can assist health care organizations in assessing climate-related infrastructure and care-delivery vulnerabilities at both a system and facility level. These checklists are available both as a single document here (see links below) or individually at the end of each element section.

Who should participate in completing the checklists? Resilience requires a multi-disciplinary approach. At a minimum, representatives from Facilities, Security, Engineering, Sustainability, Environmental Services, Nursing (Clinical Care), Supply Chain, and Emergency Planning might all participate in the exercise. In addition to internal staff review, community partners and government relations may need to be included to provide broader community and regional context during the exercise.

Tasks for Element 1:

• Maintain up-to-date data on climate hazards and community climate and health vulnerabilities, and use hazard vulnerability analyses to inform health services and infrastructure planning today and for the future (out to 20–50 years). 
• Develop a comprehensive understanding of the role of the hospital, long-term care, and ambulatory settings within the community during and after identified extreme weather events, and use this knowledge to inform resilience strategies.

Recognize your climate risks

Identifying climate risks and community vulnerabilities is an important step in defining health care delivery system resilience. Health care organizations are encouraged to conduct a climate risk assessment so that they may better understand and catalog present and future extreme weather risks. Hospital and health systems that operate multiple campuses (in many instances across varying climate zones) should complete climate risk assessments for each of their sites. Hospital systems should carefully consider how each campus interacts with its community, as well as how resources and capacity might shift if extreme weather affects some or all of a system’s regional assets.  These considerations may be particularly relevant in comparing the needs of urban and rural facilities—for example, during or following a disaster a rural community may rely on its hospital for essential community services, such as food, water or basic shelter, while an urban setting may provide a wider array of essential emergency services, reducing pressure on the hospital to provide broader community services.

Work with others

Similarly, it may be important to meet with local and regional governing authorities or planning departments to understand preferred local and regional risk assessment methodologies and tools. Climate risks are highly variable across the United States; some are gradual (like sea level rise) while others are becoming more extreme today. The Climate Resilience Toolkit offers a set of tools that hospitals can use to gather information on climate hazards. Climate risks have inherent uncertainty, a necessary by-product of climate models that use many inputs to characterize probable outcomes for particular times and locations. In light of these complexities, additional technical expertise may be available through local universities, municipal planning departments, or consultants.

Consider climate in the context of other hazards

The need to embrace a multi-hazard approach is essential, especially for facilities located in areas that may be exposed to a variety of extreme weather hazards. While this checklist and resources focuses on climate-related hazards, hospitals must consider a broad range of additional risks, from bio-terrorism to pandemics. Multi-hazard assessments can reveal potentially conflicting effects of mitigation measures. Thus, the results of a climate risk assessment should be included in an organization’s larger Hazard Vulnerability Analysis (HVA).

Key resources for climate projections

Climate Inspector: Provides users with a way to review four different climate projections for any given location.  Explore projected changes in temperature or precipitation, and download maps, trend data, or projected annual cycle data. Requires some understanding on the variation between climate models.

NOAA Climate Change Portal: This portal lets users display or download climate projection output from the Coupled Model Intercomparison Project (CMIP5) that informed the IPCC Fifth Assessment Report. Contains user-friendly drop down menus of models, atmospheric fields, and time.

Key resources for mapping graphics

CanVis: This software gives users an opportunity to modify maps and photos of a campus or facility to visualize impacts of projected sea level rise. This downloadable photo-editing program gives users the power to generate “after” pictures illustrating possible futures.

Climate Outlooks: This site provides access to maps showing experts’ judgments regarding chances for above-, below-, or near-average temperature and precipitation, as well as potential hazards and drought conditions, with timescales ranging from weeks to years.

Coastal Flood Exposure Mapper: This visualization site gives users a way to overlay risk maps and produce unified images.  Provides local maps to stimulate discussions about the people, places, and natural resources exposed to coastal flooding. Users create a collection of maps showing risk from various hazards.

FEMA Flood Map Service Center: This center helps users find, view, analyze, and print flood hazard maps to identify threats and risks for specific locations and facilities.

Hazus: This downloadable software provides access to FEMA models for estimating potential losses from earthquakes, floods, and hurricanes and evaluating costs and benefits of mitigation options.

U.S. Drought Portal: This site provides a range of information and services related to drought including early warnings, climate data, and decision support services.

Tasks for Element 2:

• Understand and catalog the land use, building design, and regulatory context within which the health care facilities are situated. Ask: Are site improvements and existing building structures adequate to withstand extreme weather events now and in the future? Ask: What were the design assumptions for roads, stormwater quantities, building envelopes and structures, and roof drainage systems? 
• Consider the larger local and community land use vulnerabilities that may impact health care facilities in the face of extreme weather—aging or inadequately sized infrastructure or removal of natural buffers.

Check your site’s surroundings

It is important to understand the design parameters and regulatory framework under which existing health care buildings were constructed. Recent extreme weather events suggest that historical baselines are inadequate for ensuring future building performance, especially for critical buildings such as hospitals and residential care facilities. An understanding of the building structures and their potential vulnerabilities is essential for improving facility climate resilience.

Definitions for relevant terms

Critical Facility: Facilities for which the effects of even a slight chance of disruption would be too great a threat to life, health, and welfare. Critical facilities in the 2012 International Building Code are classified as Risk Category III and IV facilities. Risk Category IV includes buildings and structures that, if severely damaged, would reduce the availability of essential community services necessary to cope with an emergency. Risk Category III buildings and structures house persons with limited mobility or ability to escape to a safe haven. Example: Risk Category IV includes designated public shelters, hospitals, vital data storage centers, power generation and water and other utilities, and installations which produce, use, or store hazardous materials. Risk Category III includes residential care facilities and small health care, schools, and prisons (FEMA 2014).

Critical Infrastructures: Includes assets, systems, and networks, both physical and virtual, that support campuses and buildings, and that are so vital that their destruction or incapacitation would disrupt the security, health, safety, or welfare of the public. Example: critical infrastructure can be man-made (such as structures, energy sources, water, transportation, and communication systems), natural (such as surface or groundwater resources), or virtual (such as information systems) (DHS 2013).

Checklist

The Element 2 Checklist assists health care organizations in understanding land use, site, and building design vulnerabilities. The Element 2 Checklist includes questions about site access, transportation, landscape, building envelope, and vertical transportation systems.

Key resources (external links)

Understanding Your Risks: Identifying Hazards and Estimating Losses. This guide provides step-by-step guidance on how to perform a risk assessment.

Design Guide for Improving Hospital Safety in Earthquakes, Floods, and High Winds: Providing Protection to People and Buildings. Information presented in this publication provides an exhaustive review of mitigation measures and design solutions that can improve the safety of hospitals in natural hazard events.

Design and Construction Guidance for Community Safe Rooms. This publication presents design, construction, and operation criteria for both residential and community safe rooms that will provide near-absolute life safety protection during tornado and hurricane events.

FORTIFIED® for Safer Business. This program offers a new construction checklist tool describing improvements that can increase new, light-commercial-use buildings’ durability and resilience to natural hazards. May be appropriate for medical office buildings and ambulatory settings.

Green Building and Climate Resilience: Preparing for Changing Conditions. This report summarizes recent research on the likely impacts of climate change at various scales. The report includes predicted climate changes by region, describing characteristics such as future temperature, precipitation, coastlines, air quality, pests, and fires.

Tasks for Element 3:

• Construct and retrofit critical facilities with sustainable communications, energy, water, and waste infrastructure in appropriate locations and to a standard of climate resilience to withstand events over the anticipated life of the structure. Infrastructure resilience measures reduce disruption, incapacitation, or loss of use of critical health care facilities.
• For less critical facilities: design for safe closure prior to an event with the ability to resume services within 48 to 96 hours following a major event.

Examine facility infrastructure

Infrastructure protection and resilience is a key element of health care facility operation through extreme weather events. In Hurricane Sandy, the failure of both grid power and emergency generators forced hospital evacuations. While generators were located above flood elevations, critical infrastructure components—fuel pumps, fuel tanks, electrical switchgear—were not. This element examines energy, water, and waste infrastructure, as well as fire protection and communication systems. All of these components are necessary to continue to provide care and/or safely “shelter in place” during and after an extreme weather event.

Uninterrupted energy supplies are required to maintain operational health care facilities during and following an extreme weather event. While all hospitals include emergency generators for temporary emergency power supplies, extended grid power outages are testing the limits of this technology, and emergency generator plants may be situated in vulnerable locations. Increasingly, hospitals are investing in on-site power generation through combined heat and power technologies to improve resilience. In addition to power interruption, loss of climate control systems (heating and air conditioning), air filtration, building pressurization, and other key mechanical performance measures may lead to the need to evacuate the facility.

Secure access to water

Access to reliable potable and process water supply is a key element of health care resilience. There is no national standard for quantity of reserve backup; one of the key challenges with fixed-quantity emergency water supplies is accurately estimating demand. Storage of large quantities of water is often difficult and impractical, but ensuring 24/7 availability of water delivery is equally challenging. A range of measures can improve water supply resilience: dual water sources (i.e., on-site wells), water conservation, on-site rainwater harvesting, and reclaimed water reuse systems. Municipalities in drought-prone regions are installing large-scale municipal reclaimed water systems to meet the process (non-potable) water needs of their communities. In hospitals, up to 70 percent of total water use is for non-clinical care uses. Finding reliable alternative sources of water is a key element of enhanced resilience in a future with stressed potable water supplies.

Checklist

The Element 3 Checklist assists health care organizations in understanding key mechanical/electrical/life safety infrastructure vulnerabilities. The Element 3 Checklist includes questions about communications, energy, water, and waste system infrastructure at both building and campus levels.

Key resources (external links)

Combined Heat and Power: Enabling Resilient Energy Infrastructure for Critical Facilities. This report provides information on the design and use of combined heat and power (CHP) for reliability purposes, as well as state and local policies designed to promote CHP in critical infrastructure applications.

ASHRAE Advanced Energy Design Guide  (for Large Hospitals)  (for Small Hospitals). The series provides an approach to easily achieve advanced levels of energy savings without having to resort to detailed calculations or analysis. The Guides offer contractors and designers the tools, including recommendations for practical products and off-the-shelf technology, needed for achieving a 50 percent energy savings compared to buildings that meet the minimum requirements of ANSI/ASHRAE/IESNA Standard 90.1-2004.

Targeting 100! Envisioning the High Performance Hospital: Implications for a New, Low Energy, High Performance Prototype. This research provides a conceptual framework and decision-making structure at a schematic design level of precision for hospital owners, architects, and engineers. It offers access to design strategies and the cost implications of those strategies for new hospitals to utilize 60 percent less energy.

National Renewable Energy Laboratory Atlas. These maps show renewable energy resources in the United States. They illustrate the geographic distribution of wind, solar, geothermal, and biomass resources, as well as other pertinent information.

U.S. Department of Energy—Renewables Make a Powerful Case as Hospital Energy Source. This short primer offers an introduction to tools and resources for assessing sites’ potential for tapping renewable energy. The guide includes short case studies of hospitals that have integrated renewables into their energy portfolios.

Planning for Water Supply Interruptions: A Guide for Hospitals and Health Facilities. This short primer highlights tools and resources for assisting hospitals and health facilities in preparing for water supply interruptions.

Emergency Water Supply Planning Guide for Hospitals and Healthcare Facilities. Health care facilities should develop an Emergency Water Supply Plan (EWSP) to prepare for, respond to, and recover from a total or partial interruption of the facilities’ normal water supply. Because a health care facility must be able to respond to and recover from a water supply interruption, an EWSP provides the guidance to assess water usage, response capabilities, and water supply alternatives.

Task for Element 4

• Ensure that essential clinical care services remain operational during and immediately following extreme weather events.

Often, hospitals must both shelter inpatients in place as well as handle patient care surges related to a weather event. Emergency departments, urgent care centers, laboratory, and imaging services must remain operational. Nursing homes and residential care facilities house medically fragile, vulnerable populations. Research facilities may lose irreplaceable samples and data. In addition, health care settings may serve important non-traditional disaster response roles in their communities: sources for clean water, food, and shelter for a larger affected population.

Despite disabling situations, be ready for a surge in demand

Hospital facilities, in emergencies, are responsible for more than sheltering inpatients or residents in place—they are often called upon to deliver medical services to large numbers of injured people. It is imperative that hospitals maintain not only operational infrastructure services, but also vital medical care delivery services.

Even if vital mechanical and electrical infrastructure is out of harm’s way, medical care delivery—from submerged imaging departments to flooded corridors connecting egress and transfer pathways—can be severely hampered. Surges of patients often follow weather disasters; with disrupted transportation, patients with minor injuries may be unable to leave safely following treatment. Ground-level helipads may be unusable because of debris or flooding, hindering evacuation or transfer. At the same time, search and rescue operations may necessitate debris removal and route clearance, traffic control (including personnel restricted movement), fuel distribution for response vehicles, and assistance in maintaining civil order from hospital personnel.

Ensure adequate supplies and staffing

Hospitals must stockpile supplies in advance of events to remain operational through extended transportation and supply chain disruption. Just as critical, hospitals require personnel ranging from medical professionals to environmental services workers to deliver both direct patient care and necessary support services. Transportation systems may be damaged; travel restrictions and gasoline rationing may further stress personnel movement and re-supply. Hospitals and residential care facilities should have effective personnel recall systems coordinated with local and regional emergency management systems. During and following extreme weather events, hospitals and residential care settings may be required to house large numbers of workers, their families, and even their pets in order to continue to deliver high-quality, uninterrupted care while cut off from transportation systems and re-supply infrastructure.

Element 4 examines the organization of programs and buildings for uninterrupted health care service delivery and patient surge management both during and following extreme weather events.

Checklist

The Element 4 Checklist assists health care organizations in assessing clinical care and supply chain vulnerabilities. The Element 4 Checklist includes questions about provisions for patient surge, alternate care sites, staff accommodation and transportation, and provisions for community support to ensure that essential clinical services can continue without interruption during and immediately following extreme weather events.

Key resources for managing surge (external links)

The Joint Commission: It is crucial that health care organizations understand what surge hospitals are and how they can plan for and establish them. Where outside of its own walls does a health care organization go to expand its surge capacity? This paper provides the answers to these questions and offers real-life examples of how surge hospitals were established on the Gulf Coast.

Hospital Surge Capacity Toolkit: This toolkit is intended to assist healthcare facilities in thinking through critical issues related to healthcare surge, and to create comprehensive plans to address these needs.  All documents are available for download in a zip file.

Managing Mass Fatalities: A Toolkit: This comprehensive toolkit evolved from recognition of the need for communities to increase their preparedness for managing mass fatalities. Toolkit materials are based on lessons learned from actual events, including the Oklahoma City bombing, 9/11, and Hurricane Katrina. The toolkit provides scalable, operational direction and tools to guide jurisdictions in creating a local plan.

Tasks for Element 5:

• Protect and support ecosystems and natural buffers to mitigate extreme weather hazards that may threaten your building or campus. Green infrastructure practices, heat island mitigation, and enhanced stormwater management are key contributory strategies. 
• Understand that ecosystems, wildlife corridors, and natural hydrology patterns extend beyond individual property boundaries; engage the broader community in applying best design practices for adapting to extreme weather risks in order to mitigate future damages to property and people. 

Support local ecosystems

Healthy ecosystems support life and health. The United Nations Millennium Ecosystem Assessment states: “ecosystems are critical to human well-being—to our health, our prosperity, our security, and to our social and cultural identity.” Ecosystem services include vegetation and soil organisms and non-living elements, such as bedrock, water, and air. Property owners may be unaware of critical community infrastructure vulnerabilities, ranging from dams, levees, and flood control systems to disrupted stream flow and the impacts of high density development on outdoor ambient temperatures.

This Element explores how sustainable development practices can improve the operation of functioning ecosystems and how sustainable practices improve resilience. The following ecosystem service strategies should be supported as a component of resilience planning:

• Treating water as a resource: Eliminate unnecessary irrigation and harvest rainwater (where possible). Improve groundwater infiltration, filter stormwater, and reduce runoff.
• Valuing soils: Practice sustainable landscaping methods. This extends to supporting local and sustainable agricultural systems, serving healthy food, and modeling this behavior for the larger community.
• Preserving and enhancing vegetative cover and open space: Maintain wildlife corridors, habitat, wetlands, and reduce development footprint. Minimize heat-island impacts.
• Pollution prevention initiatives: Effective waste management systems, including chemical management protocols, that both reduce the hazardous waste stream and keep these pollutants out of the environment is important.

Checklist

The Element 5 Checklist assists health care organizations in assessing site and infrastructure adaptation efforts. It includes questions about pollution prevention initiatives, ecosystem protection and restoration, and participation in community climate adaptation efforts.

Key resources (external links)

Stormwater Management Best Practices: Access EPA resources based upon Integrated Management Practices for design, construction, and management of stormwater systems.

Green Infrastructure for Climate Resiliency: Find a range of tools and resources that can assist property owners manage floodwaters, prepare for drought, reduce urban heat island impacts, reduce demand for energy and potable water, and protect coastlines.

The Case for Sustainable Landscapes: Any landscape holds the potential to improve and regenerate the natural benefits and services provided by ecosystems in their undeveloped state. This guide presents the case for developing landscapes that enhance ecosystem services.