Planning for Healthcare Resiliency
Tom Sieniewicz and Kim Way
Healthcare institutions are beloved in their communities: people donate to them, they volunteer in them, and they have strong emotional connections to them. Because hospitals play a central civic role, we view them as places of solidity. Even in times of crisis, when we are at our most vulnerable, we expect hospitals to be up and running.
This means that for a healthcare provider, “resiliency” — the ability to withstand and quickly recover from a disruptive event — is essential. We are increasingly aware of the threats facing major population centers, thanks to Hurricanes Katrina, Sandy and Harvey; terror attacks like 9/11 and the Boston Marathon bombing; even the potential for earthquakes in the Pacific Northwest. Yet many cities and healthcare institutions remain ill-equipped to ensure “business continuity” in the event of a disaster.
Planning professionals have a profound role to play in creating more resilient healthcare. System-, community-, district- and even regional-wide solutions offer the best hope for resisting unforeseen natural and unnatural stresses — scales at which planners, both inside and outside of healthcare, are already skilled at operating.
Moreover, because many healthcare systems are ahead of the curve when it comes to resiliency, the strategies they are implementing offer profound insights into how we — how everyone — can become more resilient.
Those strategies can be categorized into healthcare planning solutions, architectural solutions for healthcare that also have planning implications, and larger urban planning solutions that impact industries beyond just healthcare.
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University Medical Center New Orleans
New Orleans, LA, USA
One of the most important planning tools for healthcare is zoning. Particularly in New Orleans, where the threat of flooding is ever-present, establishing the base flood elevation is an essential first step to creating resilient facilities. When designing two new, post-Katrina hospitals in New Orleans — for University Medical Center (UMC) and the Veterans Affairs (VA)-operated Southeast Louisiana Veterans Health Care System (SLVHCS) — NBBJ worked with the Federal Emergency Management Agency (FEMA) and the Army Corps of Engineers to establish a first floor that would be out of harm’s way: three feet above base flood elevation. While this was mandated by the VA, a federal agency, it should be an unquestioned first step on any healthcare project in areas where flooding is possible.
Elevating a hospital, however, can have a detrimental impact on the urban fabric. At the Medical University of South Carolina in Charleston, building the Ashley River Tower above the 100-year floodplain — and locating parking underneath it — would have created dead streetscapes, so we converted the front of the garage into sacrificial spaces for administrative use. With the additional activity this provides, along with an arcade referencing the vernacular architecture of the city, the hospital maintains a more welcoming frontage at street level. (Then the challenge becomes how to access a front door located a full story above grade, here accomplished with a ramped, landscaped entry plaza.) The larger question is how to balance the often “bunker”-like mentality of resiliency with the need to be a welcoming, urban-facing institution.
Facilities and Infrastructure Assessment
Most large healthcare providers occupy not a building, but a campus — an entire chain of buildings that are linked together and codependent, often constructed during different eras to differing standards. As a result, most campuses encompass at least one facility that is nearing the end of its functional lifespan, a building whose sudden failure could interrupt key infrastructure across the entire campus. In this context, it is essential to continually assess the condition of campus facilities and to plan retrofits to — or replacements for — vulnerable buildings as soon as those weaknesses are discovered.
In a similar vein, new construction presents an opportunity to plan for upgraded infrastructure such as power or steam systems that could function as campus-wide backups for continuity during a natural disaster. We advise our healthcare planning clients to tie these new systems back into adjacent hospital structures wherever possible to make the campus as a whole more resilient.
Healthcare organizations can also look beyond their own walls and form district-wide solutions with neighbors across the street. Adjacent institutions are beginning to realize that redundant systems for secondary power, heat and steam generation can be shared. Boston Children’s Hospital and Brigham and Women’s Hospital entered into such a discussion recently. After all, in times of crisis, organizational boundaries matter much less than the health and safety of the community, and the failure of one institution can negatively impact other nearby institutions that are forced to take up the slack.
New Orleans provides a cautionary tale about such partnerships, however. Veteran patients would occasionally be transferred from the VA to University Medical Center for certain procedures, so UMC had to meet the same federal standards for flood elevation, utilities on upper levels, parking requirements and more. But then connectivity became an issue, when plans to connect the two facilities with a pedestrian bridge over Galvez Street fell through. Although both institutions agreed a bridge would help with patient transfers and help them to survive together during a catastrophic event, no one could agree on how to fund it, so the bridge was never built. For partnerships to be successful, therefore, there must be alignment on how they will be funded.
Southeast Louisiana Veterans Health Care System
Replacement Medical Center, New Orleans, LA, USA
Healthcare design firms have pioneered the use of architectural features to ensure healthcare resiliency, but some of these features have planning implications as well.
On the design side, the University Medical Center and the Southeast Louisiana Veterans Health Care System hospitals in New Orleans are oriented “upside-down,” placing non-mission-critical functions that can tolerate flooding, such as cafeterias and conference centers, on the lower levels. Critical functions like inpatient rooms and the emergency department, on the other hand, are located on higher floors, above the flood line. The higher floors also include a secure emergency operations center for use by city, state and federal officials and first responders during a natural disaster, with technology for communicating information to the public.
(“Upside-down” design can benefit commercial developments as well: recent proposals by Foster + Partners and NBBJ for Brooklyn’s low-lying Red Hook neighborhood situated “sacrificial” uses such as parking on the ground level, with all occupied spaces and essential mechanical systems above the flood line.)
Where upside-down design isn’t possible, another strategy is to harden facilities that are planned in a more traditional fashion — for instance, using flood doors. These proved effective at Baylor College of Medicine in Houston, where basement flood doors kept out the floodwaters of Hurricane Harvey and allowed the hospital to remain open throughout the storm. (Of course, this isn’t a foolproof solution: the old University Medical Center in New Orleans had floor doors at the loading dock that failed to seal properly during Hurricane Katrina, and the facility flooded anyway.) This applies to vertical circulation as well: stairwells and elevators need to be either hardened against floodwater, or able to continue operation when flooded, perhaps by stopping at the second level after water penetrates the lower levels of the shaft.
Beyond New Orleans, the new Perkins + Will-designed Spaulding Rehabilitation Hospital also incorporated lessons from Hurricane Katrina. In particular, designers noted how, as described in the book Five Days at Memorial, the air conditioning stopped working at Memorial Hospital and the building became so stifling that staff had to break the windows to get fresh air. Accordingly, Spaulding was designed with operable windows, one of the few recently constructed hospitals in the United States to incorporate them. Under normal conditions the windows are locked so no one can throw the HVAC off-balance, but should the HVAC systems fail, staff can unlock the windows with a key to open them. This relatively simple solution can make a huge difference in situations when district power needs to be conserved or is unavailable.
Spaulding was also one of the first healthcare institutions to convince its electric utility that transformer vaults should be located on the roof, above 100-year flood levels. That may not sound particularly relevant to a planner, but it means that high-voltage lines must extend through the building superstructure to the roof before the voltage can be reduced to a usable level. Essentially, Spaulding Rehabilitation Hospital is a private, habitable building with a public utility core running vertically up it. That core had to be protected and the utility given permanent access, in order to service it when necessary. Often the best solutions require healthcare institutions to engage with infrastructure — which conventionally runs underneath public, city streets — and with utility providers in a whole new way.
Meridian Center for Health kitchen learning center
Meridian Center for Health storm water mitigation
Facility design can also play a key role in resiliency by connecting the community to health and wellness. Unlike most healthcare facilities which are designed to serve a single purpose, the Meridian Center for Health in Seattle has a life outside the typical workday and the provision of healthcare services. Conference rooms are repurposed in the evenings for community groups like the Girl Scouts, social services can occupy space within the building, and the wide driveway was designed to accommodate booths for farmers’ markets and other local events on weekends. Because the Meridian Center is knitted into the daily life of its community, it will be more likely seen as a haven in times of crisis. Moreover, because community-facing uses like these aren’t essential to clinical operations, they can be located on the ground floor in flood-prone areas.
Urban Design and Planning
The most disaster-resilient facility in the world is of no use, however, if it can’t be accessed in an emergency. Design features can ensure continued access to some extent: helicopter landing pads, for instance — though they will be unusable during a hurricane — or, in the case of University Medical Center and the Southeast Louisiana Veterans Health Care System in New Orleans, parking ramps that can double as boat launches in cases of severe flooding. But planning at a regional scale plays perhaps the most important role.
In New Orleans, Interstate 10 is elevated above grade, which made it a place of refuge and evacuation staging area during Hurricane Katrina. Recognizing this, the designers of University Medical Center, along with the State of Louisiana, considered building a ramp directly off I-10 into UMC at an upper level—until someone pointed out that I-10 returns to grade only a few miles north, greatly limiting its use as an evacuation route. Charleston faces similar challenges, where flooding can push so much debris onto the elevated roadways that they become impassable.
The “upside-down” approach to hospital planning works at a district-wide level too. Take South Boston, or what’s commonly called the Seaport District. In the nineteenth century it was built with two levels of transportation, a ground level with railway access, and a street level fifteen feet higher for horse carriages and buildings’ main entrances. As a result, the district is already set up beautifully to anticipate sea-level rise. The vestiges are there still, particularly in the Boston Convention Center, whose main entrance on Summer Street is a full story above grade, with service access down below.
In that same district in Boston, designers proposed a concept to reuse an obsolete, city-owned dry dock and convert it to public swimming pools. As the number of “dog days” each summer increases, cooling the population through public swimming —whether in pools, the river or the harbor — might emerge as a direct response to resiliency. Moreover, healthcare providers could play a key role in establishing this cooling infrastructure, as ultimately their operations will be the ones affected by the number of people potentially seeking emergency care in a heat wave.
Resilient Linkages, Boston. A responsive infrastructure creates an aqueous Central Park that doubles as a water management system.
Planners can also learn from historic precedents. The one-two punch of Hurricanes Carol and Edna in 1954 coincided with a period of maximum deforestation of the New England landscape, which led to historic flooding. We discovered then that natural systems—forest canopies and the ability of root-bound soil to absorb and slow runoff—have tremendous power to resist inundation. So in the 1960s, on the upper reaches of the Charles River, the Army Corps of Engineers, rather than build levees like in New Orleans, purchased thousands of acres of wetlands which now serve as a civic-scale stormwater retention system, a protected, natural “sponge” that has maintained the river’s ability to resist inundation in the course of major rain events.
The next step is to reproduce a similar condition the best we can in dense, urban environments. A regional response to resiliency will continue to emphasize the importance of permeable surfaces that allow water to percolate naturally through the ground. Some healthcare institutions have been proactive in this regard—Neighborcare Health in Seattle and OhioHealth in Columbus, Ohio, are just two systems that have built bioswales and stormwater retention landscapes on their campuses. The more we can mimic these natural conditions at an urban scale, the more resilient our communities will become.
With all the extra cost and effort that goes into planning for resiliency, it’s reasonable to ask, why locate healthcare in vulnerable areas in the first place? Yet institutions can’t always move away from the problem. Hospitals must serve people where they live, and if that’s a flood-prone area, they must plan accordingly. A large percentage of the United States population lives on the coasts, and we can’t simply abandon every coastal city. For academic medical centers too, the clinical, academic and research components are all symbiotic—one side can’t divorce itself from the others, and relocating everything is prohibitively expensive. The best sites might be less than ideal, so the question becomes how to plan and design facilities in those areas.
Although resiliency matters to everyone, healthcare providers are uniquely qualified to convene and lead the conversation. Partners Healthcare, which runs a consortium of hospitals in Boston and throughout New England, recognized Boston’s particular susceptibility to sea level rise, so they convened a full-day conference that brought world experts on sea level rise and resiliency together with the design community. The roundtable was the first of many conversations to anticipate what to do as a community, what to advocate for, and how hospitals can plan for a more resilient future.
This sense of responsibility, perhaps, derives from the culture of healthcare, which always tries to anticipate human suffering and eliminate it in advance. But community hospitals can become community leaders by driving this conversation, by pulling government and the private sector along to realize that resiliency is something we neglect to plan for at our peril.
There’s also a wonderful poetry in that — by coming together we become more able to withstand disaster. How many times must we learn that lesson, that as a group we’re much stronger than as individuals? That extends to institutions as well as to people, to the very foundations of our communities.