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KI & IIDA NY Healthcare Forum: Resilience As Sustainability

OfficeInsight | September 9, 2013

by Peter Carey

If Hollywood disaster movies had their way, New York City would have been destroyed 100 times over by now. Real world events may not appear to be nearly as menacing as what imaginative filmmakers may dream up, however, natural and man-made disasters in New York and across the country are becoming more frequent, as well as increasingly more expensive and complicated to fix. On 9/11 this year, twelve years after the terrorist attacks that shook this country to its core, the New York Chapter of the IIDA held an engaging and lively discussion at the KI New York showroom on the healthcare industry's approach to designing responsibly for unexpected events. As we all know, healthcare environments, dealing with some of the most vulnerable populations, are probably the best proving grounds for testing ideas about the built environment. Weakness that don't show up - or, if apparent, are considerably attenuated - in populations that are healthy and most adaptable, become obvious in the healthcare context, and lessons learned there can be applied elsewhere. 

While the day of remembrance may not have been at the forefront of the discussion, it cast a tone to the proceedings that focused on the aftermath of Hurricane Sandy and how the storm affected local hospitals and healthcare providers. Speakers Ophelia Roman, Deloitte, Robin Guenther, HOK, and Deborah Breunig, KI, gave thoughtful analyses and insightful recommendations. 

Deborah Breunig, a registered nurse and Vice President of Healthcare for KI talked about sustainability, especially as it pertains to contract furniture. Her presentation leaned toward the values of LEED and BIFMA level certification. This focus, of course, was already pretty well understood by many in the audience. For others, it provided a good foundation. For all, it served to remind that the efforts of USGBC are, at present, limited, but that sustainability concepts are also inextricably tied to the issues presented by the trauma of abrupt climate change and hazardous conditions, and the need for adaptation strategies. It is all of a piece. 

This, of course, is a very complex message, one that sustainability advocates in all areas are struggling to understand. The two other speakers, however, very nicely placed some of these issues in a greater context to help us better comprehend the breadth of where sustainable thinking will take us. 

"We had over 6,400 patients evacuated in New York City alone," said Ms. Roman in her opening remarks regarding the effects of Hurricane Sandy. She is a manager of strategic risk services for advisory firm Deloitte, and worked on a task force for Mayor Michael Bloomberg on rebuilding and resiliency after Sandy. 

"Over thirty-two hospitals and othe rmedical facilities closed during the time of Sandy," said Ms. Roman. "Six hospitals closed before, during and after the storm; five of them remained closed for an extended period of time." Appoximately 80% of bed capacity was lost during the storm; ten other hospitals in New York remained open, but experienced flooding or power outage. "Just because they didn't close does not mean they were operating normally," she said. "They were all using workarounds." Twenty-six nursing homes and adult care facilities closed during the same time, and thirty other facilities remained open, but were located in areas that experienced flooding or power outages. 

Storm surge, the unstoppable wall of water that occurs at the leading edge of a hurricane, was the main reason most hospitals were forced to evacuate. "Even though hospitals may have hundreds of critical systems they rely on every day," said Ms. Roman, "some have a much larger impact than others." Evaluating all hospitals citywide, access to emergency power was the make-or-break decision that determined evacuations from healthcare institutions. "When we say emergency power, it is not just generators. It is fuel tanks, pumps and electrical switches. If any part of that system breaks down, emergency power is lost," Water and HVAC systems were also critical as to whether a hospital was able to stay open during the emergency event or not. 

Right now, New York City has eleven hospitals that are at risk of flooding. "That is 18% of bed capacity and 10% more than the bed capacity that was temporarily lost during Sandy," said Ms. Roman. "We have eighteen nursing homes and nineteen adult care facilities in the same situation. We know which critical systems are at risk and which ones are the most important. If we want to avoid evacuation, we have to address them." 

The task force that Ms. Roman participated in published recommendations that deal with building code changes more than anything else. "We want to make sure emergency power generators and pumps are always accessible; we also want a pre-connection for external emergency generators. Once a hospital is operating on its emergency generator, it is at continuous risk," she said. "Those generators are not necessarily meant to run for a week straight." 

The task force's findings were published in a book titled A Stronger More Resilient New York. "These are citywide recommendations, she said, speaking to the audience of design professionals. "As you all work with different healthcare providers, resilience is made up of a lot of individual actions. It matters where your building is and how it is structured; it matters where the critical systems are located. For each individual provider, even with these recommendations, I can't tell you that they won't have to emergency evacuate one day. Each institution has its own individual characteristics. As we look to protect the entire city, we looked at evertyhing holistically." 

Where does the A&D community fit into the resiliency planning? As the sole designer on the panel, Ms. Guenther, a principal at Perkins+Will and a healthcare design authority, discussed hos resiliency and sustainability are intertwined. "As we see the sustainability movement evolving, you realize how, in many instances, green design approaches lead to an ingerently more resilient building in the face of a climate disaster," she said. Citing author Tom Fisher and his book Designing to Avoid Disaster, Ms. Guenther noted, "We have gotten into a world where we have what he terms fractured critical infrastructure. Only one thing has to go wrong and the whole thing tumbles. That is exactly what resilience thinking is about. Resilient natural systems are not fracture critical. They have redundances and backups in the natural system." 

Cycling thorugh a series of slides depicting the aftermath of extreme weather, Ms. Guenther returned to a quote from Mr. Fisher in his TED talk. "He says this: We should start with the assumption that nothing will work as intended or even at all. We are really at our best when we have thought about and account for the worst that could possibly happen." 

She contrasted that statement with another from Kenneth Langone, chairman of the board at NYU Langone Medical Center, who was a patient at the time of Sandy and was evacuated. "He said: We believed we had the machines, we believed the machines would work, and we believed everything we were told about the scope and size of the storm." 

It is important to note that resilience thinking originated from studies of ecosystems in different environments around the world. The many complex and interwoven layers of relationships in ecosystems may at first be invisible and may take millennia to fully understand. Resilience thinking is not necessarily focused solely on adaptability; essentially, resilient ecosystems are inherently adaptable. 

Ms. Guenther then threw out a term that was unfamiliar to most of the audience: passive survivability. "That is really the new term for this condition," she said. "Passive survivability can be helped in the built environment by low-energy design, operable windows, on-site power generation, on-site renewable energy, and independent water sources." Showing a few examples that illustrated her point, she showed on a slide of a hospital in Kansas that was leveled during a recent tornado. "When they built the town back, they built a critical access hospital that runs on wind power. It is the first 100% renewable energy hospital in the country," she said. Another slide depicted a hospital in Haiti after their earthquake. "It is a completely solar hospital. There are many hospitals growing up after these disasters that are saying they will not become dependent on fuel tanks and those kinds of systems," said Ms. Guenther. 

Sharing smart design innovations like placing critical infrastructure on a building's roof or second floor emergency rooms accessed by ramps. Ms. Guenther also touched on the idea of co-working as a solution for helthcare professionals. Co-working is a style of work that involves a shared working environment, which can also be a gathering place for people who work independently, but share like-minded values. "A number of New York hospitals are beginning to think about setting up satellite co-working areas where their staff can continue to do their job even if they can't physically make it into Manhattan after one of these disasters," she said. "Until I started looking at all of this post-Sandy, I didn't realize how little we understand about how information moves from impacted regions to us, and also what we think of as 'belonging to us.'" 

Ending her presentation with the story of 29,000 rubber ducks that were accidentally dumped into the Pacific Ocean from a cargo ship in 1992, Ms. Guenther noted, "These ducks move around the planet and now wash up one at a time, years later, on beaches across the world. Similarly, we produce a lot of material in our built environments that will not be in the building after a sotrm surge. There is still a lot od debris from Sandy out there, and that debris will be moving around for a very long time. Sometimes I talk about chemicals in building materials, and I talk about having those chemicals in our bodies, but I think we alos have to imagine for the worst. We have to imagine in New York where all the things we put in our buildings could end up, and what they will do along the way in the natural world." 

IIDA Healthcare Committee Co-Chair Renaldo Pesson moderated the question and answer portion of the evening, and ended up asking the most interesting questions himself. On the subject of the recommendations from the book A Stronger More Resilient New York, he inquired of Ms. Roman whether she thought the task force's published findings go far enough. "Resiliency is at the individual building level," said Ms. Roman. "It is also not just about the built environment; it is the staff and how they interact with the environment as well. All New York hospitals have expansive emergency preparedness programs. If these had been commercial buildings in the same areas, we would've seen a lot more of them evacuated. It wasn't that the healthcare porviders were not prepared; they were just not prepared enough," she said. "Part of it was they were relying on 1983 FEMA flood maps and thought they were at a lot lower risk." 

For healthcare and design professionals alike, estimates and predictions are satic and fixed in time. "What we tend to do is focus on the thing that immediately happened to us, and we solve for that problem," said Ms. Guenther. Sharing a story about a US hospital designed to combat a SARA epidemic, she noted that "They designed a LEED Gold Certified building that used 100% outside air. There have been three major forest fires in their area since the building was constructed; each fire shut them down. 

"I think we have to help our clients elevate the conversation beyond whatever happened yesterday. I was sitting here, of course, realizing this event is on 9/11. Yes, there was a loss of power that time too, but there were also significant air quality issues. We didn't really talk about that. What have we done as an industry in the twelve years since then is to think aobut how we buffer our ability to breathe in an event like that. No one thinks about that now because everyone is thinking about flooding from Hurricane Sandy." 

Mr. Pesson posed another question to the panel. "How shortsighted are we thinking about the disaster du jour rather than thinking about the entire compromised healthcare approach to catastrophe and disaster?" Ms. Roman, who has also done disaster planning simulations for FDNY, remarked "There is a reason why we say 'all hazards' now. You can't pick the disaster, but it is likely there will be some healthcare providers that will have some part of their building that does not have everything they are used to working with. It could be staff, it could be supplies; we have to really explore what resiliency means. And you also have to think about how disasters are evolving. The sea level rise is a perfect example, but there are others," she said. 

Turning his questioning to a member of the audience, Mr. Pesson reached out to Kristin Moore, Director of Healthcare at DIRTT for a few words on flexible spaces. "I am just coming off of horrific flooding in my home city of Calgary," she said. "What flexibility means to me is that it is not just being able to anticipate or have resilience built in, but it is the time that it takes to recover. 

"One of the things we all need to be thinking about is changing our behavior and how we are actually buildilng environments. One of the biggest challenges with conventional construction is that we know what drywall and water does when they mix. We are at the mercy of a linear construction process that is hoping after a time of disaster that the drywall contractor is available. One of the things I saw in Calgary with our clients that used DIRTT walls was that because we did not have fixed in-place construction, they were able to remove the front tiles of the walls before the water came in. They took the tiles off and moved them to a higher location; they were flooded, but they did not have to worry about the wet drywall. Once the space was dried out and sanitized, they put the tiles back up." 

Ms. Guenther, who was on the New York City Building Task Force, remarked, "The question posed to the team was, "What is an acceptable period of disruption for a hospital from an event like Hurricane Sandy? We settled on the idea of four days, which is the typical emergency fuel supply. We added one caveat: things must be repairable with on-site resources. Some of what New York City hospitals have learned is that some of their basements that flooded happened to have asbestos in them. They could not pump their basements without fear of contaminating the water supply." 

The speakers, event space and networking opportunities at this particular IIDA NY Chapter Healthcare Forum presented some truly engaging ideas and connections. Incorporating resilience thinking with a flexible reaction, regardless of what issues are anticipated or remembered was the theme of the night. This was presented in the context of healthcare design, an understandable and very instructive context. Realistically, however, the issues presented in this context are applicable, in varied forms, in most other context. Certainly, a thorough analysis of trade-offs, timelines and priorities within the scope of a healthcare institution's limited resources can give way to a successful project in any environment. 

Thanks to KI for sponsoring another impressive event by IIDA NYC. KI's new showroom design looked wonderful, as did its products on display. 

Peter Carey is President of Streamline Material Resourcing, a strategic partner for design firms and end users. Streamline manages resource libraries and the flow of design and product information for his clients. He can be reached at (347) 351-1000 or

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