Improving hospital survivability: tools to inform hospital planning and design

McNeil, SueThe scale and impact of recent natural disasters and the threat of climate change has increased awareness of the vulnerability of our built environment to disruptions. Major storms, such as Hurricanes Katrina and Sandy, have shown how these and other disaster events can negatively affect our health care infrastructure. Such disruptions are not new and are likely to continue in the future. National efforts, like the National Infrastructure Protection Plan and the National Health Security Strategy, recognize medical treatment facilities as key components of community emergency response for the preservation of the health, safety, and welfare of the nation's citizens. To be effective, hospitals must be prepared to remain operational during and after a disaster. We need a more comprehensive understanding of hospital functionality and the risks they face in order to devise more effective ways of ensuring the continuity of health care operations. This project sought to develop and apply lessons from disaster science and hospital emergency management to medical facility planning and design for the purpose of improving the survivability of nonstructural systems to increase the likelihood that medical treatment facilities will remain operational following disasters. Three tools were developed to improve the manner in which planners, designers, health care professionals, and emergency managers consider hospitals and their survivability during and after disaster events. The project's objective is to develop a policy recommendation to the U.S. Army that will improve the manner in which the Service approaches the planning and design of military medical facilities. The tools are an influence diagram, hazard vulnerability mitigation framework (HVMF), and illustrative optimization model. The influence diagram improves our understanding of the elements and influences that bear on hospital functionality. It provides a comprehensive view of the internal and external systems necessary to maintain the continuity of health care operations. The HVMF establishes a systematic approach to understanding hazards, their characteristics, exposure, vulnerability, and consequences as a basis for identifying protective actions to increase hospital survivability. The optimization model is a scenario-based decision support tool that illustrates the importance of planning and modeling in understanding complex problems. It demonstrates the quantification of a loss of service and its impact on the delivery of health care. The findings rely primarily on the qualitative analysis of expert panels consisting of health care professionals whose comments and recommendations led to the improvement and refinement of the influence diagram and HVMF. Additionally, secondary analysis of qualitative and quantitative data gathered from focus groups of medical treatment facility staff members experienced in hospital emergency management provided insights into hospital functionality, hospital support to communities, and the priority of services and support systems during disasters. The research led to several observations. First, hospitals are strategic assets for the communities in which they operate. They have capabilities that are either unique or available within a limited number of organizations in a particular jurisdiction. Hospitals also serve non-traditional roles during disasters such as providers of shelter, food, water, information, pharmaceuticals, and supplies. Second, hospital functionality during disruptions is not simply about resources but also the flexible arrangement of those resources and organizational adaptability to meet changing health care demands. Third, the functional relationships among the diverse hospital systems can be captured in an influence diagram providing a graphical representation of the possible vulnerable elements and implications of failure. Fourth, the HVMF provides context for hazards, vulnerabilities, and possible protective actions to increase the survivability of hospital systems. Fifth, optimization models, with the limitations of their completeness, assumptions, data quality, and accuracy, provide insights into the process and complexities of problem solving. Sixth, having a comprehensive understanding of risks and identifying protective actions is different from prioritizing those actions and making capital investment decisions. The tools and findings from this research support informed decisions, but they do not recommend courses of action or solutions. The project led to the identification of three key recommendations to improve the manner in which the U.S. Army approaches health care facility planning and design. First, stakeholders should determine what role the hospital will have in community disaster response and incorporate that during planning and design. Second, the design team should maximize support of operational flexibility in facility planning and design. Third, we should apply a holistic approach to understanding risk that entails a comprehensive analysis of threats, exposure, vulnerabilities, and consequences so that mitigation and preparedness actions are grounded in the specific circumstances of a facility or organization. Code compliance is the baseline, not the end state. Combined, these recommendations tie planning and design decisions to stakeholder expectations for the continuity of hospital operations. They acknowledge the importance of internal and external systems for flexible health care delivery to meet changing patient demands. Finally, they recognize the need to base protective actions in a comprehensive analysis of threats, vulnerabilities, and consequences.University of Delaware, Department of Civil & Environmental EngineeringPh.D