Introduction: The City That Continuity-Tests Itself
Most metros plan for the disaster they imagine. Houston hospitals plan for the ones they have already survived — and the region’s recent history gives them an unusually honest curriculum. Tropical Storm Allison drowned the Texas Medical Center’s basements in 2001. Hurricane Harvey dropped roughly 50 inches of rain on the Houston area in days in August 2017. Winter Storm Uri then demonstrated, in February 2021, that a Houston hospital can have power, staff, and an intact building and still be stopped cold by the absence of water.
This is a local-resilience audit for Houston healthcare operators: what the published after-action record from Allison, Harvey, and Uri actually shows, and the flood-and-water audit a facility in the region should be running on itself — because in Houston, these are not scenario-planning exercises. They are maintenance schedules for events that recur.
The Allison Lesson, Bought and Paid For
In June 2001, Tropical Storm Allison stalled over Houston and flooded the Texas Medical Center — the largest medical complex in the world, a 2.1-square-mile district of hospitals, schools, and research buildings. Contemporary accounts collected by Rice University’s Kinder Institute describe facilities flooded, patients evacuated “sometimes in the dark,” and generators knocked out by basement flooding; at Baylor College of Medicine, research animals in the basement died in the floodwater. The storm’s damage pattern was specific: the water did not defeat the hospitals’ clinical capability. It defeated their basements, where the era’s standard design had put electrical switchgear, generators, and pumps.
The response, over the following decade and a half, was capital rather than paperwork. As the Kinder Institute’s retrospective summarizes, medical-center hospitals installed floodgates and flood walls, moved generators out of basements, added pumping systems, and hardened the district against a repeat. Individual systems went further: MD Anderson built interior and exterior flood walls and relocated electrical life-support systems after Allison’s flooding forced evacuations there. The region, in other words, converted an after-action report into concrete — which is what distinguishes a lesson learned from a lesson merely documented.
Harvey: The Investments Met Their Storm
Hurricane Harvey, in late August 2017, was the test the investments were built for. Roughly 50 inches of rain fell on the Houston area over several days — more than many U.S. cities receive in a year — producing catastrophic urban flooding. The Texas Medical Center’s performance, by the published record, was the Allison investments working as designed: by the Tuesday after landfall, all 23 hospitals in the medical center were operational, with the single exception of Ben Taub Hospital, which experienced flooding around the facility and had to stop accepting new patients for a period — a planned evacuation there was halted when it became clear the hospital could ride out the storm, and inpatient care continued.
MD Anderson’s published account is the detailed version. Flood walls held; although water entered parts of the basement and lobby of the main building at the height of the rain, electrical power was never lost and no inpatient was evacuated. The center ran a ride-out model: a team of roughly 1,000 clinical, facilities, dining, housekeeping, and security staff stayed on site for days, caring for 538 inpatients, emergency-center patients, and nearly 300 family members sheltering with them. The visible cost was outpatient care: appointments and surgeries were cancelled for nearly a week, a deliberate triage that protected the inpatient core. Elsewhere in the region, the controlled version of evacuation also appeared — Memorial Hermann Sugar Land moved all 150 of its patients out and closed temporarily, in advance and in order, rather than mid-crisis.
Two planning facts follow. First, the ride-out team is a staffing system, not a volunteer list: it requires pre-designated rotations, sleeping and feeding capacity for staff and sheltering family members, and pay and relief policies settled before the storm — because a ride-out clinician whose own family is unprovided for is a staffing risk, not a resource. Second, the evacuation decision at Ben Taub — prepare, then stand down — is a governed decision point that belongs in the plan, with criteria, not an improvisation.
Uri: The Water Problem
Winter Storm Uri, in February 2021, attacked a different dependency. Extreme cold knocked out power generation across Texas and froze water infrastructure statewide; in Houston, municipal water pressure collapsed as lines burst and residents dripped faucets to protect their own pipes. The city issued a boil-water notice. According to the Texas Commission on Environmental Quality, more than 1,000 public water systems statewide reported disruptions affecting more than 14 million people.
For hospitals, the binding constraint was water, not electricity — generators largely held; the water system did not. Houston Methodist’s president and CEO described two of the system’s hospitals — Houston Methodist West and Houston Methodist Baytown — losing city water supply entirely, one for over 48 hours and the other for over 72. The system brought in 6,000-gallon tanker trucks, imposed significant water restrictions, and facilities across the region curtailed elective procedures; reporting from the week describes sterilization, dialysis, sanitation, and food service all degrading simultaneously, because all of them are water systems wearing different names. The pattern repeated in miniature in November 2022, when a power outage at Houston purification plants dropped distribution pressure below the threshold in Texas rules — 20 psi — at which a boil-water notice is obligatory, and the city issued one again.
The continuity translation: in Houston, water must be planned as a utility that can fail independently of power, for days, metro-wide — which defeats the standard assumption that a neighboring facility or a municipal workaround will be available. Everyone in the region is short of water at the same time.
The Continuity Audit: Flood and Water
Flood defenses as maintained equipment. Floodgates, barriers, walls, and pumps are only assets if they deploy. The audit items: a deployment drill with a measured time from decision to sealed; gasket, seal, and pump maintenance on the same schedule discipline as generator testing; and a named owner for the deploy decision, because a floodgate that requires a committee is a wall decoration. The federal floor is the CMS Emergency Preparedness Rule — see our guide to its four core components — but Houston’s record argues for treating flood defense as a tested system, not a construction feature.
Electrical and fuel above the line. The Allison pattern — generators, switchgear, and fuel systems in the basement — is the single highest-value audit in the region. Anything that remains below grade needs a documented reason and a compensating measure.
The ride-out roster, costed. A ride-out plan that names the team size the facility can actually feed, house, and relieve for four days; family-sheltering provisions, because Houston’s own experience put nearly 300 family members inside one facility; and pre-signed relief and mutual-aid arrangements for the day-five problem, when the ride-out team’s endurance, not the building, becomes the constraint.
Water, in hours. State the facility’s water position as a number: hours of full operation on stored and contracted supply, and hours more under a defined restriction regime (elective procedures paused, sterilization prioritized, dialysis triaged). Tanker contracts should name capacity and trigger — MD Anderson’s and Methodist’s experience says the call goes out when the whole metro is calling. Add the boil-water playbook: what changes clinically and operationally the hour a notice is issued, and who owns the all-clear decision when it lifts. Our disaster recovery plan testing guide covers how to exercise this without discovering it live.
Evacuation criteria written in advance. Harvey gave the region both models in one storm: a full, orderly, pre-emptive evacuation (Sugar Land) and a prepared evacuation stood down on conditions (Ben Taub). The audit question is whether your criteria for each are written, owned, and rehearsed — and whether business-interruption coverage actually matches the outpatient-closure scenario, the likeliest financial event. Our business interruption insurance guide addresses the coverage side; the integration with clinical continuity frameworks is in our healthcare continuity compliance guide.
Frequently Asked Questions
What is a ride-out team?
The pre-designated staff who remain inside the facility through a storm’s impact period, when travel is unsafe or impossible. MD Anderson’s Harvey ride-out team numbered roughly 1,000 across clinical, facilities, dining, housekeeping, and security functions and stayed for days. A functioning ride-out model includes sleeping and feeding capacity, family-sheltering provisions, and relief rotations — it is a logistics system, not a call list.
What did the Texas Medical Center change after Tropical Storm Allison in 2001?
After Allison flooded basements, knocked out generators, and forced evacuations, medical-center hospitals invested in floodgates and flood walls, relocated generators and electrical systems out of basements, and added pumping capacity. Those investments were widely credited when, during Harvey in 2017, all 23 medical-center hospitals remained operational except Ben Taub, which temporarily stopped accepting new patients.
Why did Houston hospitals struggle during Winter Storm Uri if their generators worked?
Because the failed utility was water. Frozen and burst lines collapsed municipal pressure; the city issued a boil-water notice; two Houston Methodist hospitals lost city water entirely for over 48 and 72 hours respectively. Sterilization, dialysis, sanitation, laundry, and food service are all water-dependent, so a hospital with full electrical power still had to restrict operations and haul water in by tanker.
What triggers a boil-water notice in Texas?
Under Texas Commission on Environmental Quality rules, a drop in distribution pressure below 20 psi is the trigger the City of Houston cited when it issued its November 2022 notice after a treatment-plant power outage — pressure that low can allow contamination into the lines, so the notice is obligatory until testing clears the supply.
How long was MD Anderson disrupted by Harvey?
Inpatient care was never evacuated and electrical power was never lost, but outpatient appointments and surgeries were cancelled for nearly a week while the region’s roads were impassable. That asymmetry — inpatient continuity preserved, outpatient revenue interrupted — is the financial shape Houston facilities should plan and insure against.
Continuity Hub’s metro series audits local resilience the way the national guides audit frameworks. The companion pieces cover New York City and Seattle–Tacoma.