The Evolving Importance of Health Care Resiliency

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Provided by Engineered Systems


When a natural disaster strikes a community, a hospital can serve as a beacon of safety – but only if the facility’s vital systems have not been compromised. Without adequate power, ventilation, and water, a hospital quickly loses its ability to provide service and safety to patients and staff.

To ensure a facility can remain operational during such an event, the MEP infrastructure needs to be sufficiently protected and hardened. The first step toward increasing this resiliency is to determine what level of continuity your systems will need to maintain in the event of a disaster. Next, consider the types of threats systems may encounter and what vulnerabilities they would face against those threats.

Image courtesy of André Ulysses De Salis/Pexels

FIGURE 3. To ensure a facility can remain operational during such an event, the MEP infrastructure needs to be sufficiently protected and hardened.

While the best course of action is to have an MEP engineer thoroughly assess a facility’s risks and gaps, the following provides a high-level preview of the four main risk areas of concern.

1. Location of building system equipment — It’s not uncommon for facilities to have electrical equipment and emergency power infrastructure located in the lower level. While it might initially seem to be a good idea to have these systems in non-premium spaces, locating them in the lowest level of a building increases the risk of flood damage. This is especially dangerous if a hospital is in a floodplain or a building is at or below sea level.

During the planning stages, one of the simplest steps a designer can take to reduce the risk of flooding affecting the MEP systems is to locate critical equipment on higher levels. For example, the generators at Memorial Medical Center in uptown New Orleans were able to withstand the initial impact of Hurricane Katrina in 2005, but the flooding in the following days reached the emergency power transfer switches, expediting the evacuation of the facility.

2. Hardness of systems — Hardness refers to the process of reinforcing individual systems within a hospital to make them more resilient against disaster. For example, during the planning stages of the Advocate Aurora Summit Hospital in Wisconsin, it was decided to locate the central utility plant 500 feet away from the hospital, connected with a utility tunnel. One of the main drivers for segregating the central utility plant from the main hospital was to hedge against a disaster impacting both locations simultaneously. The remote plant also allowed for the space to house underground fuel storage to allow the generators to run for 96 hours.

3. Redundancy — Baseline redundancy for critical infrastructure items, such as boilers, medical gas, and power, are required by code for health care facilities, but additional redundancy should be a key consideration when evaluating the resiliency of the MEP systems. For instance, assume the building load is 1,000 ton of cooling and the facility is equipped with two 500-ton chillers. If one chiller breaks down or is compromised, the facility will only have 50% of the required cooling capacity available. To safeguard against this potential problem, an engineer could plan for one of the following:

  • Purchase a backup 500-ton chiller to have on hand in case of emergencies;
  • Have three 500-ton chillers to have an N+1 capacity, or, in other words, 100% backup available should a single chiller fail;
  • Upsize both chillers to be 750 ton, so 75% of capacity will be present if one fails; and
  • Install outside piping to bring in an emergency backup chiller when needed.

Though this example is specific to water chillers, the importance of having redundancies and backup plans can be applied to all necessary systems and processes in a hospital. For instance, consider the plumbing system. What would a designer do if a resident could no longer flush toilets? This leads to the next consideration: potable water.

4. Potable water — Other than pallets of bottled water, it’s rare for hospitals to store water. This can lead to significant problems if something interrupts the water supply. How will an individual flush toilets or wash and sterilize equipment? How much drinking water will the facility require over a certain time period?

To answer these questions, first determine how much water usage a facility needs. A week’s worth of water might not be as much as one thinks. Once the usage is understood, a designer can make an informed decision of how much water will be needed in an emergency. While on-site water storage is the best solution to this potential problem, a facility manager can also contract with a pumper truck to be available in emergencies.

One also can enact procedures to save and reuse water. Plan to shut off water to designated, nonessential areas of the hospital; use recycled water to flush toilets; or install a roof drain for condensation recovery.

By proactively addressing these four potential MEP system vulnerabilities, a designer can avoid the challenges and tragedies that can occur when disaster strikes.


One of the most effective ways to increase a hospital’s physical security without creating an overly institutionalized aesthetic is by leveraging architectural elements to create secure environments. These strategies are called crime prevention through environmental design (CPTED) principles. Here’s how you can incorporate them — as well as other strategies — into your exterior and hospital entrance design.

1) Restrict the access points to the building — Designated, specific entrances for public access allows for easier monitoring and secure visitor screening. Utilizing vegetation and various architectural elements can help drive people away from entrances a facility manager doesn’t want them to use and toward the main entrance. While you need to have numerous egress doors to be up to code, there are steps you can take to ensure emergency exits are only used in the case of an emergency. With proper signage, alarms, camera monitoring, and even removing the entrance-side door hardware, a facility can better control which doors permit entry into the hospital.

2) Separate visitor and employee parking lots — One of the biggest physical security concerns every hospital should have is for their staff. To limit the potential for dangerous interactions, keep public access points separate from employee access points. By establishing a perimeter boundary for an employee parking lot, an extra level of protection is created within the parking area, so staff can move back and forth to their vehicles safely.

3) Utilize effective parking lot lighting — More than brightly lit parking lots, a facility needs evenly lit parking lots. When lighting is too bright in some areas, it can have the effect of making other areas seem darker. Instead of using big, bright lights, aim for smaller, more frequent lights that have a high level of distribution over parking lots. This can play a significant role in security by increasing visibility and improving camera coverage. The use of bollards is one of many CPTED principles that can be employed to increase the physical security of hospitals.

4) Create vehicular boundaries — Since pedestrian traffic needs to be protected from vehicular traffic, creating a clear separation between the two can minimize incidents. For example, instead of just a crosswalk, consider using pavement changes, lighting changes, and rumble strips to draw attention to the separation. CPTED principles may also be used to restrict vehicle access to buildings through bollards and curbing. Just ensure the restrictive elements being used have practical stopping power, rather than just aesthetic appeal.

Image courtesy of Sora Shimazaki/Pexels

FIGURE 4. Physical security may be strengthened by leveraging architectural elements to create secure environments.

5) Limit access to ambulance delivery areas — Separating the ambulance delivery area from the public emergency entrance will limit confusion and ensure an intruder isn’t gaining access to your hospital through a vulnerable and often chaotic area. This can be as simple as creating an environment the public won’t be drawn to or isn’t readily visible from the front of a hospital, which can be done with additional vegetation or barriers.

6) Consider after-hours traffic — It’s not uncommon for hospitals to have all after-hours traffic enter through the emergency department. While this is a fine solution, it’s still important to consider what this policy does to a facility’s parking access. How far away from that entrance are people going to have to park? What kind of exposure will they have while walking to and from their cars? In order to make this a safe option, a facility manager may need to consider additional lighting and protective barriers.

7) Utilize glass vestibules as boundaries for secure entry — The entrance to a hospital should be warm and welcoming — but it also needs to be safe. Fortunately, security can be increased by creating a glass vestibule to act as an additional set of doors necessary to gain entry. Depending on the location of the hospital and the risk for gun violence, staff could consider making the entrance glass bulletproof. At minimum, the facility should have laminated glass so it won’t immediately shatter if hit.

8) Make emergency departments escapable — Admitting and waiting areas in emergency departments are often high-stress spaces in which tempers can flare. To protect employees working in these areas, create safe points and escapable options in case they feel threatened. For instance, while a desk can act as an initial boundary, having an additional exit behind the desk through which the employee can slip out if threatened adds an extra layer of protection.


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Originally published in June 2022