How to be Resilient in a World of Creeping Climate Change

Jim Crabb, PE, LEED AP

Principal - Mechanical
8/31/22

Many healthcare systems are aware they need to think about the impact of a changing climate on their ability to deliver effective health services. This awareness likely stems from the increasing frequency and severity of climate change-driven disasters. These disasters have included year-round wildfires, increasingly intense rain events and flooding, unseasonable freezes and record-setting heat.

As community health safety nets, healthcare organizations feel a strong impact from these events. Many of our healthcare clients have firsthand experience of how these events hurt or even prevent their ability to deliver care. They and other healthcare systems either have made or increasingly understand the need for detailed emergency and disaster preparedness and recovery plans to address the acute effects of climate change.

Yet not all consequences of climate change are immediate. What we are increasingly concerned about is how and whether healthcare systems are prepared to deal with the creeping climate crisis—relentless, if less perceptible, climate changes that nonetheless will erode institutions’ ability to deliver high quality, cost-effective care. One of the challenges the physics of climate change poses is that the greenhouse gasses we emit remain for decades, even centuries, in the atmosphere, doing their warming work.

Even if we all stopped emitting now, the gasses already in the atmosphere will continue to warm the earth and change our climate in harsh and relentless ways. We are not stopping our emitting ways, so healthcare institutions will be managing the effects of climate change beyond the foreseeable future.

In this note, we’ll share some of our thinking and experiences as healthcare facility designers and engineers working with an array of clients on strategies and tactics for adapting their facilities to prepare for the creeping effects of climate change. We’ll explain some of the key areas affected and offer some of the latest thinking about how healthcare organizations can build longer-term resiliency into their facilities and strategies to weather the constantly accruing effects of climate change.

The persistent consequences of creeping climate change

Disasters leave obvious destruction in their wake. The consequences of creeping climate change are less immediately visible but are persistent and growing. That means healthcare organizations must consider the likely climate condition of their world not only today, but 10, 30, even 50 years from now as they devise resiliency and adaptation strategies to help ensure uninterrupted care delivery. Critical focus areas include:

Energy costs and availability 
Our clients are increasingly concerned about the reliability of their energy sources. Power grids around the country are stressed. Record-setting heat results in greater demand as businesses and consumers lower their thermostats. Drought leads to insufficient snowpack to melt and power hydroelectric dams. In the now year-round fire season, electric utilities may cut power to prevent lines sparking and igniting dry brush. Some California utilities have begun to bury power lines, the high costs of which will be passed on to consumers. Energy prices are likely to rise even as reliability decreases.

Reducing overall energy demand is the best adaptive strategy. This can start with an energy audit that encompasses mechanical, lighting, air handling and HVAC systems as well as use by individuals throughout a campus. Planning to eliminate the use of natural gas for heat and domestic hot water reduces operating cost while cutting carbon emissions.

Other adaptive strategies to consider include deploying renewable power sources. On-site renewables effectively fix the cost of energy as a hedge against rising prices. Hydrogen is particularly promising, although it requires a specific source design different from today’s conventional systems. After one of our clients implemented hydrogen fuel cells in a new facility, energy prices fell and the investment seemed wasteful. But the fuel cells effectively insulated the organization against later spikes in energy costs.

Water imbalances 
Hospitals need water to operate, and in many areas, that’s becoming a scarce, expensive resource. The southwestern US is suffering from the worst drought in at least 1200 years. Water supplies to Western states are being cut as we write. Reduced water threatens the ability to generate electricity. That includes hydroelectric sources, nuclear and even fossil fuels because these plants rely on healthy water supplies for cooling. Urban regions throughout the country deal with water stress. In addition to drought, water stress is created when there’s competition for limited usable water supplies among municipalities, business, agriculture and recreation. As major water users, healthcare systems often contribute to and feel the effects of this stress.

Healthcare campuses in areas that rely on underground aquifers for water likely will face increasing costs for this water because municipalities tend to increase use restrictions when aquifers are pumped faster than they can be replenished. We worked with one client in this situation that bought nearby farmland and its water rights, then put solar panels on the land. The client avoided penalties for overuse of water while reducing its greenhouse gas emissions by incorporating solar power into its energy mix.

In extremely drought-prone or other water-scarce areas, healthcare systems may consider installing onsite water treatment facilities. These usually need large storage tanks to operate, but can add to a facility’s resilience if the municipal water supply is interrupted. Treating water only to the required level of usability, as our clients do in India, can be cost effective for larger systems. “Grey” water, effluent that’s treated but not to potability, can be used for grounds watering and HVAC cooling systems.

Auditing water use throughout the healthcare campus and taking steps to use water more efficiently are good initial steps. Landscape irrigation and cooling towers are water hogs. Organizations can reduce landscaping water needs by swapping out thirsty exotic plants with better-acclimated native plantings and using drip irrigation or soaker hoses for less waste. To save water, one of our clients is evaluating whether to replace an older cooling-only chiller with a heat recovery chiller that both reduces cooling tower water use and displaces a fossil gas heating plant.

The flip side of the water story is dealing with too much of it. Being aware of changing flood plain maps and whether a campus or other care delivery facilities are in new flood plains is vital. FEMA mapping, and sometimes community specific mapping is the basis for setting elevations of structures. Each municipality typically has code requirements related to flood plains. The general rule is that a structure needs to be located 1 foot above the 100-year flood plain. So-called “100-year floods” now happen more often. Recently we’re hearing about 500- and 1,000-year flood events, so the time is right for considering elevations beyond code-minimum.

Hospital air quality 
It’s a common myth that code-required ventilation rates are calculated to reduce hospital-acquired infections. In fact, regulations governing hospital ventilation are based on concepts and values developed in the middle of the 20th century, when energy was cheap and climate change only the faintest notion. The health benefits of high ventilation rates are unknown, while it’s certain they increase energy use and carbon emissions.

Climate change will make the energy/carbon penalty even higher. Research is urgently needed to determine what level of ventilation is really needed in hospitals – rather than relying on 20th century rules of thumb.

For example, wildfires are becoming continuous threats that reduce local air quality with smoke clouds that may last days or weeks. Increasing ventilation rates only exacerbates the problem. Ventilation systems need to remove both particulates and gaseous pollutants from smoke to provide a safe, odor-free indoor environment. Smart design will apply new technologies and new analytical tools to achieve this goal at minimum energy and carbon cost.

Adverse effects on new care delivery models 
The current US healthcare trend is to push care closer to consumers, from neighborhood clinics to “hospital at home” models. Satellite facilities are unlikely to be as risk-hardened as those on a healthcare campus. After Hurricane Sandy, dialysis centers went down across the New York region, resulting in poor outcomes for kidney patients.

Similarly, healthcare systems investigating lower cost care-at-home options must think about how power outages, heat waves, cold spells, etc., could affect in-home monitoring and care delivery.

Building to appropriate facilities standards 
The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) reports that cooling design temperatures have increased globally by an average of 1.4 degF from the 1980s to the early 2000s. Climate models are projecting steeper increases in coming decades. Building designs based on historic trends may not perform as expected as local climate changes. Health facilities being built today will experience higher temperatures, more frequent climate-related adverse events and more extreme events over the next 30 to 50 years. The world around the buildings will be changing, and buildings must be engineered to withstand future conditions – without adding more carbon emissions to the problem.

Compliance with changing environmental regulations
States and municipalities now commonly enact increasingly strict mandates for buildings in their jurisdictions to reduce emissions. These requirements are often poorly tailored for the unique needs of healthcare buildings. Even the more thoughtful regulations will impose new costs on a healthcare institution, especially if it has any poorly designed or out-of-date structures. Designing defensively now will reduce impact of changing codes in the future. Better yet, hospitals can engage in the rule-making process to steer regulations toward rational, evidence-based regulations that weigh environmental cost against actual benefits.

Supply chain challenges
As the COVID-19 pandemic showed, healthcare’s supply chain is global and affected by international weather events, disasters, socio-political upheavals, etc. One of our clients has a full-time staffer whose job is to monitor weather events in industrial centers around the world so that the health system can anticipate effects on its supply chain.

What to do next about creeping climate change

Dealing with the emerging and potential consequences of creeping climate change is undoubtedly a challenge. Healthcare organizations have many competing priorities and resources can seem scarce. The recommendations below offer a way forward that’s sustainable and scalable. These steps help integrate climate adaptation strategies into business and operating strategies. Instead of climate resiliency being an outlier, it becomes central to an organization’s mission of delivering high quality care.

Develop a comprehensive environmental, social and governance (ESG) policy
Hospital boards already have ESG on their to-do lists. That’s in part because financial markets likely will reward organizations with solid ESG progress with more advantageous rates on bond issues. The Centers for Medicare & Medicaid Services (CMS) has asked healthcare organizations to voluntarily pledge to reduce their emissions. It’s not a big stretch to foresee a day when CMS includes ESG considerations in reimbursement models.

ESG policies also inform trading partners and suppliers, local businesses, the community and internal stakeholders about the healthcare organization’s resiliency and emissions goals. A good policy guides every department in making ESG related decisions, from operating suites to mechanical operations. The policy can raise awareness of the creeping climate issues and help build support for adaptive and mitigating steps.

Issue RFPs that reflect the future state of the climate
RFPs should require designs and specifications for water, power, HVAC, appliances, landscaping, etc., to anticipate and address future temperatures and humidity levels, water availability and cost, grid resiliency, etc. Even if somehow the world reached zero emissions this year, greenhouse gases persist and their impact on climate is inevitable.

Healthcare organizations need to ensure their investments in new systems and facilities and renovations can withstand those consequences for their financial health and to ensure continuity of care. Organizations can require vendors to explain how their solutions will perform in climate conditions 30 to 50 years from now, not just day one. Organizations should require their consultants to disclose their own GHG emissions, and how they are actively working to reduce them.

Build a comprehensive adaptation program vs. cherry picking
While it’s natural to start with low-hanging fruit or a highly visible effort, such as installing a native plant garden or touting low-flush toilets, resiliency strategies need to address all the creeping climate risks a specific organization faces. A climate risk audit will help reveal current and emerging issues and help rank their urgency.

We appreciate that investing in resiliency against creeping climate changes is a difficult balancing act. It’s a bit like life insurance. People usually buy policies hoping they’ll never need them—but the coverage is invaluable when the worst happens. Quantifying specific risks and which to address requires healthcare organizations to balance “What do we need?” queries with “What can we afford?” Is building additional capacity that might be underused in the near term a good hedge to make against future influxes of zoonotic diseases? Or should investment go to alternative power supplies or lower-carbon infrastructure?

These are difficult calculations to make. That said, the better approach may be to determine what’s needed, then be creative in affording it. As with preventive care for patients, the ability of a healthcare organization to withstand tomorrow’s climate consequences depends on its willingness to take steps toward resiliency today.


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Amy Pitts, MBA, BSN, RN

Senior Technology Consultant

Andy Neathery

Technology BIM Specialist

Angela Howell, BSN, RN

Medical Equipment Planner

Angelica Chow, PE, LEED AP BD+C

Electrical Engineer

Anjali Wale, PE, LEED AP

Senior Associate, Senior Electrical Engineer

Arturo S Salud

Associate, Senior Electrical Designer

Austin Barolin, PE, CEM, LEED AP O&M

Senior Associate, Senior Energy Analyst

Beth Bell

Chief Financial Officer

Bethany Beers, CCP, LEED AP BD+C

Sustainability Practice Lead

Bilal Malik

Associate, Senior Electrical Designer

Brennan Schumacher, LEED AP

Associate Principal, Lighting Design Lead

Brian Hageman, LEED AP

Associate Principal, Plumbing Discipline Lead

Brian Hans, PE, LEED AP

Associate Principal, Senior Mechanical Engineer

Brian J. Lottis, LEED AP BD+C

Associate, Senior Mechanical Designer

Brianne Copes, PE, LEED AP

Senior Associate, Mechanical Engineer

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