Climate change is altering both the frequency and severity of hazards relevant to hospital operations. The Intergovernmental Panel on Climate Change has concluded that human-caused climate change is already affecting weather and climate extremes in every region, with risks escalating as warming increases (1). The 2024 Lancet Countdown documented record climate-related health threats and emphasized that health systems face growing demand even as climate hazards undermine delivery capacity (2). For a hospital, these are not abstract environmental trends. They appear as heat illness, respiratory exacerbations during wildfire smoke, injuries during storms, infectious-disease shifts, evacuation decisions, supply interruptions, utility instability, and staff unable to reach work.

The World Health Organization (WHO) defines a climate-resilient, low-carbon health system as one able to anticipate, respond to, cope with, recover from, and adapt to climate-related shocks while minimizing greenhouse-gas emissions (3). This definition is valuable because it joins resilience with mitigation without confusing them. A hospital can lower emissions yet remain unable to operate through a water outage; it can also install redundant diesel generation while leaving patients, staff, and the community exposed to pollution and fuel disruption. Executive governance must address continuity and environmental performance together, but with explicit objectives and measures for each.

Climate threats differ from many conventional emergency scenarios in three ways. First, they can develop slowly, recur seasonally, and then become acute. Second, they cross organizational boundaries: electricity, water, transportation, telecommunications, pharmacies, laboratories, home health, emergency medical services, and public health may fail or surge together. Third, exposure and adaptive capacity are unequally distributed. People with chronic disease, limited mobility, unstable housing, low income, outdoor occupations, or dependence on electrically powered medical equipment may experience greater harm and fewer options.

This review asks how hospital leaders can convert climate risk into an operating model for continuity of essential services, resilient facilities and supply chains, workforce protection, community coordination, and responsible capital allocation. It emphasizes testable capabilities over aspirational plans. We present this article in accordance with the narrative review reporting checklist.

This was a narrative review designed for hospital boards, executives, facility leaders, emergency managers, supply-chain leaders, and clinical operations teams. Searches were completed on 12 August 2026. PubMed/MEDLINE was searched for peer-reviewed literature. WHO, Intergovernmental Panel on Climate Change, US Department of Health and Human Services (HHS), Administration for Strategic Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE), Centers for Medicare & Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC), Federal Emergency Management Agency (FEMA), and Environmental Protection Agency (EPA) websites were searched for current frameworks and implementation guidance. Publisher and DOI pages were used for reference verification. Table 1 summarizes the search.

Evidence was selected purposively rather than through a systematic-review protocol. Priority was given to international assessments, systematic and scoping reviews, empirical facility studies, peer-reviewed environmental-footprint research, and authoritative preparedness tools. The synthesis used a dependency model: essential clinical services require staff, space, supplies, utilities, information, and external partners; resilience depends on the weakest critical dependency and the organization’s ability to adapt when that dependency fails. No pooled estimates were calculated.

The completed evidence-synthesis exhibits are presented in Table 2, Table 3, and Supplementary Table S1.

A climate event should not be modeled as a single hazard with a single response. Extreme heat can increase emergency visits and inpatient acuity while reducing electrical reserve, degrading cooling, affecting medication storage, and increasing staff fatigue. Wildfire smoke can affect outdoor air, indoor filtration loads, employee health, and access routes. Flooding can compromise road access, below-grade utilities, sterile processing, waste removal, and vendor delivery. A severe storm may cause power, water, telecommunications, and staffing failures at the same time. The operational question is therefore not simply, “Do we have a generator?” It is, “Which clinical services remain safe, for how long, under which simultaneous failures?”

Hospital-resilience literature increasingly describes six interdependent elements: space, supplies and equipment, staff, systems, strategies, and services (4). This formulation improves on a facilities-only view. Hard resilience includes structural integrity, utilities, and protected equipment; soft resilience includes leadership, finance, workforce, logistics, communication, and relationships. Empirical work on climate-resilient facilities similarly emphasizes risk assessment across emergency management, facilities, health services, and supply chains (5). A climate plan that belongs only to facilities or sustainability is therefore structurally incomplete.

Boards should require a climate-informed hazard vulnerability assessment (HVA) that incorporates projected conditions, not only historical incident frequency. Historical data remain useful, but stationary assumptions can understate changing heat, precipitation, wildfire, and coastal risk. The HVA should score probability, severity, current controls, recovery time, and equity consequences. It should also identify correlated hazards—for example, heat plus grid stress or storm surge plus fuel-delivery interruption.

The next step is service-to-dependency mapping. For each essential service—emergency care, intensive care, surgery, obstetrics, dialysis, imaging, pharmacy, laboratory, sterile processing, oxygen, and information systems—the hospital should define minimum safe capacity, maximum tolerable downtime, critical dependencies, backup arrangements, and the authority to curtail or relocate services. This turns an all-hazards plan into operational decisions.

Climate resilience should sit within enterprise risk management and be co-owned by clinical operations, facilities, emergency management, supply chain, information technology, finance, quality, and community health. A named executive should be accountable, but distributed ownership is essential because no single function controls all dependencies. The board’s quality or risk committee should review an annual climate-risk profile, capital gaps, drill results, open corrective actions, and community vulnerabilities.

Decision rights must be specified before an event. Leaders should know who can activate incident command, defer elective work, close an unsafe area, release emergency inventory, arrange staff lodging, authorize extraordinary purchases, request mutual aid, or initiate evacuation. Ambiguity is costly when information is incomplete and time is short. Incident command remains useful, but climate resilience also requires “steady-state” governance between events: monitoring seasonal risk, completing capital work, maintaining vendor contingencies, and learning from near misses.

CMS emergency-preparedness requirements establish an all-hazards foundation for participating providers, including risk assessment, policies and procedures, communication plans, and training and testing (6). Compliance, however, is a floor. A tabletop exercise can satisfy a requirement while leaving fuel endurance, water dependency, indoor temperature thresholds, or supplier concentration untested. Executive assurance should therefore distinguish document completion from demonstrated capability.

The HHS Climate Resilience for Health Care toolkit offers hazard-specific modules that can extend the HVA into climate-informed actions (7). Its usefulness depends on integration with the organization’s capital plan and corrective-action system. Risks identified without funding, ownership, or deadlines become institutionalized vulnerabilities.

Facility resilience begins with critical-load analysis rather than generator nameplate capacity. Leaders need to know which loads are served, fuel endurance under realistic conditions, refueling dependencies, transfer-switch reliability, maintenance status, and performance during high ambient temperatures or flooding. Backup power should be tested under load and under scenarios that include failures in fuel supply, controls, or cooling. Critical electrical components, pumps, generators, and information infrastructure should be protected from site-specific flood and wind risks.

Cooling is a clinical service. During extreme heat, indoor temperature and humidity can affect patients, medications, equipment, sterile areas, staff performance, and infection prevention. Cooling systems also depend on electricity and sometimes water. Resilience plans should identify temperature thresholds by care environment, priority zones, temporary cooling options, patient-relocation triggers, and the time required for spaces to become unsafe. Energy-efficiency investments can reduce normal demand and create more useful backup capacity, but only if the redesigned system has been commissioned and tested.

Water is another underappreciated dependency. Hospitals require potable and process water for hygiene, sanitation, dialysis, sterilization, food service, cooling, and fire protection. Plans should quantify use by function; identify shutoff, conservation, and isolation procedures; specify alternate-water arrangements; and test whether vendors can deliver the required volume during a regional emergency. Water-quality events also require rapid communication and clinical guidance.

Smoke and air-quality hazards call for building-envelope and filtration strategies. Hospitals should understand outside-air intake controls, filter capability and stock, pressure relationships, and the limits of portable air cleaners. Protecting inpatient care is not enough; outpatient, home-care, and community members may seek safe air. Planning should identify whether the hospital can provide or support clean-air spaces without compromising clinical operations.

Physical access must be assessed from the perspective of patients, staff, ambulances, suppliers, and waste haulers. Redundant entrances are not meaningful if they share the same floodplain or road corridor. Regional mapping should include staff residential patterns, public transportation, bridge or rail vulnerabilities, alternate delivery points, and landing zones. Capital projects should evaluate future climate conditions across their useful life; a building expected to operate for decades should not be designed only to yesterday’s hazard envelope.

Pandemic experience exposed the fragility of health-care supply chains, but climate hazards introduce additional regional and infrastructure-specific failure modes. A supplier may remain financially healthy while its plant, port, road, electricity, or upstream raw-material source is disrupted. Hospital visibility often ends at the direct distributor, leaving hidden concentration upstream.

Supply-chain resilience should start with clinical criticality. Hospitals cannot hold unlimited inventory, so items should be classified by consequence of shortage, lead time, substitution difficulty, shelf life, and source concentration. For the most critical items, leaders should know manufacturer and geographic origin when available, approved substitutes, conservation protocols, burn-rate triggers, and mutual-aid options. The objective is not indiscriminate stockpiling; it is enough visibility and decision time to protect care.

Digital technologies can improve sensing and allocation, but a systematic review of health-care supply-chain disruptions found that practical implementation evidence for artificial intelligence, blockchain, and other tools remains limited (8). Basic capabilities—accurate item masters, inventory visibility, standardized substitute approval, vendor communication, and clear allocation authority—should precede sophisticated prediction. Technology that cannot function during a network outage is not a complete resilience control.

Contracting should incorporate resilience requirements: notification of disruption, business-continuity testing, alternate sites, data sharing, transport options, and expectations for allocation during regional shortages. Lowest unit price can be a false economy if it creates single-source exposure. Procurement evaluations should include total risk-adjusted cost and identify when redundancy or local sourcing justifies a premium.

Pharmacy, nutrition, sterile processing, oxygen, blood products, laboratory reagents, linen, and waste are particularly important because failure may force rapid clinical curtailment. Each needs a preapproved conservation ladder that protects equity and clinical appropriateness. During scarcity, transparent allocation criteria and an ethics mechanism reduce ad hoc decisions and moral distress.

Hospitals operate through people whose households experience the same event. Staff may face evacuation, school closure, power loss, unsafe air, damaged housing, or transportation disruption. A staffing plan that assumes normal availability during a community disaster is not a plan.

Workforce resilience begins with role-based minimum staffing for essential services and cross-training for scarce functions. Contact data and credentialing must be current. Team-based models should define which tasks can be reassigned safely during crisis standards. Remote work can protect administrative capacity, but remote access, cybersecurity, electricity, and connectivity require testing.

Practical supports influence attendance and recovery: safe transport, parking, on-site rest, food, water, childcare partnerships, temporary lodging, personal protective equipment, and clear compensation policies. Leaders should communicate early about expectations and avoid forcing staff to choose between family safety and unexplained work demands. Mental-health support should be integrated into operations before, during, and after events; resilience is not an instruction to tolerate preventable harm.

Occupational protections must match the hazard. Heat plans should cover outdoor workers, loading docks, ambulance crews, facilities staff, and inadequately cooled spaces. Smoke plans should specify exposure monitoring, respirator availability and fit, and work modification. Flood or cleanup work requires hazard assessment beyond usual clinical controls. Near-miss reporting should include facility and environmental hazards, not only clinical incidents.

A climate-resilient hospital is part of a regional care ecosystem. Patients may lose power for oxygen concentrators, refrigeration for medicines, transportation, dialysis access, home-health visits, or pharmacy services. Community vulnerability mapping should combine hazard exposure with health status, disability, language, housing, transportation, and access to resources. CDC and HHS tools can support this assessment, but local partnerships are essential (9).

Community-benefit planning should fund interventions that reduce predictable demand and harm: heat outreach, clean-air access, medication continuity, medically vulnerable-person registries where legally and ethically appropriate, transportation plans, and coordination with public health, emergency management, utilities, dialysis providers, pharmacies, long-term care, and community-based organizations. Hospitals should not create registries they cannot maintain or act upon.

Equity review should occur before capital decisions are finalized. A resilient flagship campus does not protect patients if community clinics, transport routes, or safety-net partners fail. Investment criteria should consider who benefits, who remains exposed, and whether a project shifts risk to another community. Communication must be accessible in language, format, and channel, including during power or internet loss.

Mutual aid should be specific enough to operate. Agreements need triggers, request processes, transport responsibilities, credentialing, reimbursement, scarce-resource principles, and communication pathways. Regional exercises should include utilities and suppliers, not only hospitals and emergency services. Climate events disregard corporate boundaries; coordination should do the same.

Health care contributes materially to greenhouse-gas emissions. US health-sector environmental impacts have been associated with substantial public-health burden (10), and global supply-chain analysis shows that health care’s footprint extends well beyond facility energy use (11). This creates both responsibility and opportunity. Energy efficiency, electrification, renewable power, lower-carbon procurement, waste prevention, and clinically appropriate care can reduce emissions and sometimes operating cost.

Resilience and decarbonization should be designed together. On-site renewable generation paired with storage can support selected critical loads; efficiency can extend backup duration; water conservation can reduce outage vulnerability; and reduced anesthetic-gas or material waste can lower environmental impact. Yet every intervention needs engineering and clinical validation. Electrification without adequate backup may create new dependencies, while emergency generators without emissions controls may harm nearby communities.

Environmental-footprint studies by Eckelman and Sherman quantified emissions and health effects associated with the US health-care sector (12), and later work estimated pollution-related health damages from health care (13). These are system-level estimates, not a performance score for any individual hospital. Leaders should use recognized accounting approaches, disclose boundaries and assumptions, and avoid unsupported claims of “carbon neutrality.” Procurement is critical because much of the footprint lies in purchased goods and services.

Clinical quality and decarbonization can align when low-value care, unnecessary travel, avoidable admissions, and material waste are reduced. Decisions should still be governed by patient benefit, safety, equity, and total lifecycle impact. Sustainability teams need clinical, finance, and supply-chain partners; otherwise, projects may remain peripheral or optimize one metric at the expense of reliability.

Resilience measures should test capability, not document volume. Useful leading indicators include percentage of essential services with dependency maps; backup endurance for critical utilities; supplier concentration for high-criticality items; workforce contact and cross-training completeness; drill participation; corrective-action closure; and community-partner readiness. Lagging indicators include service interruptions, unsafe temperature or air excursions, canceled care, evacuation, staff injuries, shortage days, patient harm, and recovery time.

Exercises should escalate from focused tests to compound scenarios. A hospital might first test automatic transfer switches, then a utility outage, then heat plus prolonged grid failure plus fuel-delivery delay and high emergency demand. Drills should include decisions to curtail services and communicate with patients. Observers should capture workarounds and mismatches between written procedures and actual capability. Corrective actions need owners, deadlines, resources, and retesting.

Capital planning should combine life-safety requirements, probability, consequence, equity, regulatory exposure, and avoided downtime. Conventional return-on-investment methods can undervalue resilience because benefits appear as losses avoided under uncertain events. Scenario analysis and real-options thinking are more appropriate: some investments preserve options, shorten recovery, or prevent catastrophic failure even when annual utilization is low. Finance leaders should make those assumptions visible rather than pretending the uncertainty does not exist.

The WHO framework identifies ten components spanning governance, workforce, vulnerability assessment, monitoring, research, resilient technologies and infrastructure, management of environmental determinants, climate-informed programs, emergency management, and finance (3). Hospitals can translate these into a maturity model. The value of maturity scoring is not the score itself; it is a transparent sequence of capability gaps and funded actions.

Implementation guidance can be organized into a maturity sequence. WHO’s overview for climate-resilient and environmentally sustainable facilities begins with a facility-level understanding of hazards, infrastructure, services, workforce, water, sanitation, energy, and waste (14). At the earliest level, a hospital knows its legal requirements and has basic emergency plans. At an intermediate level, it maps essential services to dependencies, funds the highest-consequence gaps, and tests compound scenarios. At an advanced level, climate projections inform capital design, supply and community partners participate in exercises, outcome data drive adaptation, and lessons are shared regionally.

Maturity must include organizational and human capacity. A 2024 systematic review found that hospital-resilience literature after COVID-19 increasingly emphasized psychological and workforce dimensions alongside infrastructure and management (15). A prior systematic review grouped hospital-resilience factors across preparation, response, and recovery and across staff, infrastructure, management, and logistics (16). These findings support one integrated assurance process; a facility score cannot compensate for unavailable staff, and a trained workforce cannot compensate for loss of oxygen, power, or water.

Resilience also depends on adaptive coordination. Work on surge capacity has used complexity and resilience concepts to show why centralized plans need local feedback and the ability to reorganize under changing conditions (17). Hospital indicator research has attempted to convert broad resilience concepts into measurable domains (18), while engineering research demonstrates that recovery trajectories and service performance can be modeled, not merely described (19). Executives need not adopt one universal index. They should select a small set of measures tied to local failure modes and use them consistently over time.

National preparedness doctrine provides another layer. FEMA’s preparedness goal defines capabilities across prevention, protection, mitigation, response, and recovery (20). Hospitals can map their controls to these phases and identify whether planning is concentrated on response while mitigation and recovery remain weak. EPA climate indicators provide a transparent source for observed environmental trends, but local engineering and public-health information should determine site assumptions (21). HHS has explicitly connected climate change with health equity, reinforcing that resilience investments should be assessed for distributional impact (22).

Sector-risk tools can support prioritization when used carefully. ASPR resources help health-care organizations identify critical functions and dependencies (23). The exercise should document assumptions and data age; a risk score based on an outdated generator test or vendor list gives false assurance. Independent review is appropriate for high-consequence systems, and remediation should be verified rather than closed on the basis of a purchase order.

Recovery planning is frequently thinner than response planning. Leaders should define service restoration priorities, minimum data required to resume care, staff relief, replenishment, patient follow-up, financial liquidity, claims documentation, and communication with regulators and the community. Recovery is not complete when utilities return. It includes catching up deferred care, investigating harm, replacing depleted supplies, supporting staff, and updating design standards. A resilience event should produce a funded learning agenda.

Global decarbonization road maps emphasize that procurement, energy, transport, food, pharmaceuticals, and models of care all contribute to the health sector’s footprint (24). Net-zero pathways should be connected to the same capital and clinical governance used for resilience. Professional calls for a health-care pathway to net zero likewise stress leadership and coordinated action (25). Hospitals should disclose what is measured, avoid counting offsets as operational resilience, and give priority to interventions that reduce emissions and improve health or reliability.

An annual resilience statement to the board can integrate these elements. It should report the current hazard profile, material dependencies, tested endurance, unresolved high risks, capital commitments, exercise findings, community-equity priorities, emissions boundary, and next-year objectives. The statement should name uncertainties and areas where evidence is limited. Honest uncertainty is safer than a composite score that implies control the organization has not demonstrated.

This review integrates climate science, hospital-resilience literature, environmental-footprint research, and operational guidance into one executive model. It treats the hospital as a dependency network and explicitly connects facilities, workforce, supply chains, community equity, and emissions. The search strategy and supplementary search details are documented.

The review is narrative and purposive. It did not use duplicate screening, formal risk-of-bias grading, or meta-analysis. Peer-reviewed evidence directly evaluating hospital climate-resilience interventions remains limited, and frameworks use heterogeneous definitions and measures. Government guidance reflects specific regulatory contexts and may not transfer internationally. Climate projections, infrastructure conditions, and community vulnerability are local; therefore, no generic checklist can replace site-specific engineering and clinical analysis. Financial benefits of avoided disruption are difficult to estimate and may be overstated if scenarios are chosen selectively. Finally, mitigation and resilience interventions may create tradeoffs not fully captured in published literature.

Climate resilience is the ability to preserve essential care through compound disruption and to emerge with improved capability. It requires more than emergency plans or sustainable-building claims. Hospitals need climate-informed risk assessment, service-to-dependency maps, tested continuity for power, cooling, water, air, information, access, supplies, and staff, and explicit decision rights when normal operations cannot continue.

Boards should integrate climate risk into enterprise risk, quality, capital, and community-benefit oversight. Executives should fund corrective actions, test realistic compound scenarios, protect the workforce and its families, include community partners, and measure both continuity and equity. Low-carbon operations should be pursued where they reduce harm and can be reconciled with reliability. The objective is not to predict every climate event. It is to build a hospital that can recognize changing conditions, adapt before failure, sustain essential services, recover quickly, and learn.