Pan American Health Organization · Second edition, 2026 · 46 pages
Integrated guidance for climate-resilient, disaster-safe, and environmentally sustainable healthcare facilities
- Issuer
- Pan American Health Organization
- Edition
- Second edition, 2026
- Audience
- Hospital administrators, health disaster coordinators, healthcare facility designers, engineers, maintenance personnel, ministries of health, architects, public health professionals
- Evidence
- Expert consensus and field-tested tools validated through Smart Hospitals Initiative demonstration projects in seven Caribbean countries (2015–2025)
- Reviewed
- 18 Oct 2026 · GMJ
What this guideline says
GMJ summary
The Smart Hospitals Toolkit is a comprehensive package of assessment tools and technical guidance designed to help healthcare facilities become safer, greener, and better maintained. Developed by PAHO under the UK-funded Smart Hospitals Initiative, it integrates disaster resilience, environmental sustainability, and operational maintenance into a unified framework for healthcare infrastructure planning, retrofitting, and new construction across the Caribbean and broader Americas region.
The Toolkit comprises five main sections: (1) the Hospital Safety Index (HSI) for assessing structural, nonstructural, and functional vulnerability to natural hazards; (2) the Green Guide and Checklist for evaluating and improving environmental performance, targeting 40–60% reductions in water and electricity use; (3) the Baseline Assessment Tool (BAT) for detailed audits of energy, water, indoor environmental quality, and building components; (4) maintenance planning and preventive maintenance protocols; and (5) design considerations for new smart healthcare facilities. Supporting tools include the Retrofitting Economic Support Tool (REST) for cost-effectiveness analysis, technical standards for hurricane-resistant construction, and detailed guidance on wastewater management, waste segregation, infection control, and renewable energy integration.
The core principle is that safe + green + maintained = smart. A ‘smart’ healthcare facility scores category A on the HSI (able to protect life and continue functioning during disasters), achieves 70%+ on the Green Checklist (demonstrating resource efficiency and environmental responsibility), and implements structured preventive maintenance to sustain performance over time. The Toolkit is designed for hospital administrators, ministries of health, engineers, architects, and maintenance personnel.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Apply the Hospital Safety Index every 5 years; Category A facilities protect life and continue functioning during disasters, Category B facilities resist disasters but risk equipment damage, Category C facilities endanger occupants.
- Target 70%+ score on the Green Checklist as the gold standard for environmental performance, achievable through water and energy conservation measures yielding 40–60% resource savings post-retrofitting.
- Indoor CO₂ levels: acceptable <600 ppm; 600–1000 ppm causes stiffness and fatigue; 1000–2000 ppm impairs cognition; >2000 ppm causes headaches and nausea; >5000 ppm risks serious oxygen deprivation.
- Relative humidity should be maintained at 40–60% in most hospital areas; patient wards, triage, and examination rooms require 21–24°C with maximum 60% relative humidity; operating theatres 20–24°C with 20–60% humidity.
- Lighting levels: waiting areas 100–300 lux, examination/treatment rooms 500–1000 lux (minimum), surgical field 2000–10,000 lux with high colour rendering (minimum index 90) and flicker-free operation.
- Smart healthcare facilities require minimum 3 days' (preferably 5 days') water storage based on highest consumption patterns, rainwater harvesting systems, and segregated wastewater treatment with tertiary-level standards for safe environmental discharge.
- Healthcare waste: 75–85% is general nonhazardous waste; 10–15% is infectious; 5–10% is chemical/radioactive; strict segregation at point of generation using colour-coded containers is mandatory to prevent contamination of general waste streams.
- All refrigerants must be evaluated for ozone-depleting potential (ODP) and global warming potential (GWP); phase out chlorofluorocarbons (CFCs) and hydrochlorofluorocarbons (HCFCs); prefer natural refrigerants like ammonia R-717 (ODP≈0, GWP=0) or carbon dioxide R-744 (GWP=1).
Recommended temperature and humidity levels for selected areas of healthcare facilities
Table extracted from the guideline
| Hospital area | Temperature (°C) | Relative humidity |
|---|---|---|
| Public waiting area | 21–24 | max 65% |
| Triage | 21–24 | max 60% |
| Examination/observation room | 21–24 | max 60% |
| Patient ward | 21–24 | max 60% |
| Delivery room | 20–24 | 20–60% |
| Operating theatre | 20–24 | 20–60% |
| Intensive care unit | 21–24 | 30–60% |
| Infectious isolation room | 21–24 | 20–60% |
| Laboratory | 21–24 | max 60% |
| Emergency room | 21–24 | 20–60% |
| Medication room | 21–24 | max 60% |
| Dialysis treatment area | 22–26 | max 60% (recommended) |
Source: Pan American Health Organization, Smart Hospitals Toolkit. Second edition. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- Second edition updates the toolkit with lessons learned from Smart Hospitals Initiative demonstration projects conducted 2015–2025 across seven Caribbean countries.
- Expanded section on wastewater management including tertiary treatment standards and antimicrobial resistance reduction.
- New detailed guidance on indoor environmental quality monitoring including CO₂ thresholds and air quality parameters.
- Addition of Retrofitting Economic Support Tool (REST) for cost-effectiveness analysis of smart hospital interventions.
- Enhanced maintenance section with specific provisions for preventive maintenance budgeting and computerized maintenance management systems for facilities with 50+ beds.
From the guideline
Verbatim
“A smart (safe + green + maintained) healthcare facility protects the lives of patients and health workers; reduces postdisaster damage to the hospital infrastructure and equipment as well as the surrounding environment; continues to function as part of the health network, providing services under emergency conditions to people affected by a disaster; uses scarce resources more efficiently, thereby generating savings in water and electricity in the range of 40–60% just after retrofitting.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who has worked with WHO on health systems strengthening across the South Caucasus, I see the Smart Hospitals Toolkit as directly applicable to Georgia's healthcare infrastructure modernization needs. Our 2019 national hospital infrastructure assessment identified that over 60% of facilities lack adequate disaster preparedness, and energy costs consume 8–12% of hospital operating budgets—the Toolkit's integrated Hospital Safety Index and Green Checklist methodologies could systematically address both challenges. I would particularly stress to Georgian colleagues the indoor environmental quality thresholds: our hospitals frequently operate split-unit air conditioning without adequate fresh air exchange, and I have personally observed CO₂ levels exceeding 1500 ppm in crowded outpatient departments, directly impairing clinical decision-making. The most realistic implementation caveat is maintenance sustainability—Georgia's public hospitals chronically underfund preventive maintenance, and without protected budget lines and trained personnel as specified in Section 4, even well-designed retrofits will deteriorate within 3–5 years, as we witnessed with several donor-funded rehabilitation projects in the early 2010s.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 18 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia and the South Caucasus face significant seismic risk (magnitude 6+ earthquakes), extreme weather events including floods and heatwaves, and infrastructure vulnerability that make this Toolkit highly relevant. Between 2015–2022, PAHO assessments found 82% of Caribbean healthcare facilities would require emergency measures after hazard impact—a proportion likely similar in Georgia given ageing Soviet-era hospital infrastructure. The Toolkit’s integrated approach addresses key Georgian health system priorities: the 2013 Universal Health Coverage programme requires resilient service continuity; WHO Europe’s climate-resilient health systems agenda aligns with the green hospital framework; and the Government’s 2021–2030 healthcare infrastructure modernization plan can benefit from the Hospital Safety Index and Baseline Assessment Tool methodologies. National adaptation would require incorporating seismic design standards per Georgian Building Code, adjusting HVAC parameters for continental climate (colder winters, hotter summers than Caribbean), and integrating with Georgia’s existing infection prevention and control protocols developed during the COVID-19 pandemic. The preventive maintenance framework is particularly relevant given widespread gaps in hospital maintenance budgeting and workforce across the region.
Questions this guideline answers
Quick answers
What defines a 'smart' healthcare facility according to this Toolkit?
A smart healthcare facility is Safe (Category A on Hospital Safety Index—protects life and continues functioning during disasters), Green (70%+ on Green Checklist—resource-efficient and environmentally responsible), and Maintained (structured preventive maintenance sustaining performance over time). It combines structural/nonstructural safety, environmental sustainability, and operational reliability.
How often should the Hospital Safety Index be applied?
The Hospital Safety Index should be applied at five-year intervals as a minimum, or more frequently if retrofitting is contemplated, if an emergency or disaster affects the area, or after significant infrastructure changes. Periodic application monitors facility safety status and evaluates the impact of interventions over time.
What are acceptable indoor air quality thresholds for healthcare facilities?
CO₂ levels should remain below 600 ppm (acceptable); 600–1000 ppm causes complaints of stiffness and decreased concentration; 1000–2000 ppm impairs cognitive function and causes drowsiness; 2000–5000 ppm is associated with headaches, nausea, and increased heart rate; above 5000 ppm may cause serious oxygen deprivation, permanent brain damage, coma, or death. Split-unit air conditioning does not introduce fresh air, so CO₂ builds up without adequate ventilation.
What waste segregation system should healthcare facilities implement?
Facilities must segregate waste at the point of generation using colour-coded bags and containers: general nonhazardous waste (75–85% of total), infectious waste (10–15%), and chemical/radioactive hazardous waste (5–10%). Once hazardous waste is mixed with general waste, all must be treated as hazardous. Bags should be tied when three-quarters full, and staff generating waste bear responsibility for proper segregation.
Related on GMJ
Interconnected resources
GMJ News coverage
Quality & accreditation
- ASF Hospital — Standard 18 — Sustainable Care
- ASF Hospital — Standard 7 — Governance & Management
- ASF Hospital — Standard 5 — Safety & Emergency Preparedness
- ASF Hospital — Standard 4 — Care & Treatment
- ASF Hospital — Standard 11 — Critical Care
- ASF Medical Transport — Standard 6 — Emergency Response During Transport
Other guidelines on this topic
- Recommendations for the adoption and procurement of pressure swing adsorption oxygen generator plants
- Good Practices in the Rational and Effective Use of Oxygen
- Recommendations to Prevent COVID-19 Transmission at Food Fairs and Markets
- Guidance on Indoor Environmental Quality in Health Care Facilities
- STAR-H: Strategic Toolkit for Assessing Risks in Health Facilities
- Issuer
- Pan American Health Organization
- Type
- Guidelines and Technical Manuals
- Edition
- Second edition, 2026
- Replaces
- Smart Hospitals Toolkit, First edition (publication year not specified in document)
- Status
- Current
- Published
- 2026-04-01
- Languages
- English
- Scope
- Healthcare facility infrastructure: safety, environmental sustainability, and maintenance for hospitals, clinics, primary care facilities, and specialized institutions
- Audience
- Hospital administrators, health disaster coordinators, healthcare facility designers, engineers, maintenance personnel, ministries of health, architects, public health professionals
- Pages
- 46
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-75-13175-6 (PDF)
- Evidence
- Expert consensus and field-tested tools validated through Smart Hospitals Initiative demonstration projects in seven Caribbean countries (2015–2025)
- Record history
- Created 18 Oct 2026 · updated 18 Oct 2026 · next check Apr 2027
Pan American Health Organization. Smart Hospitals Toolkit. Second edition. Washington, D.C.: PAHO; 2026. Available from: https://doi.org/10.37774/9789275131756GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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