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Saturday, February 04, 2012
Feature: April 2007
Whole Lotta Shakin’ Going On
Next year, hospitals face a decade-old seismic Deadline. Are they ready?
Story by Wes Sander
Hospitals aren’t like other buildings. Few structures involve such complexity, such intricate internal systems bringing power to sensitive machines, and doing so with high reliability. Few operate under such sharpened urgency, with the pressure to keep functioning when other buildings have lost power, even crumbled to the ground around them.
Which is why, considering the intricate building codes that follow such traits, hospital construction can be a tough line of work, and which is at least part of the reason the number of available hospital builders is always small.
It’s also why there’s so much uncertainty in the current dialogue over how to resolve California’s seismic-safety requirements for hospitals — a dialogue heard loudly these days in the Sacramento region, where the speed of new hospital construction is rivaled only by that of the Inland Empire among the state’s metropolitan areas.
The concern for structural integrity applies with a certain singularity in California, where nature’s tool for punching holes in mankind’s bubble is often the earthquake. California’s current set of guidelines traces back to 1971. That’s when the Sylmar earthquake (also known as the San Fernando Valley earthquake; the name Sylmar stuck after it was originally thought to have been centered there) struck outside Los Angeles.
The ensuing havoc included several damaged hospitals, two of which collapsed. One was still brand-new. Two years later, in 1973, California passed the Alfred E. Alquist Hospital Facilities Seismic Safety Act, which set new standards for the integrity of hospital buildings.
The Northridge quake struck in January of 1994 and damaged 23 Southern California hospitals, enough to force some to suspend services and others to shut down altogether. Total hospital damages were pegged at $23 billion.
But this time, no hospitals collapsed, and that success is generally owed to the Alquist Act. Still, like Sylmar, Northridge inspired new legislation, and later that same year, the law that is still commonly referred to as SB 1953 was created, imposing the absolute deadline of 2008 for retrofitting or rebuilding of the most at-risk buildings.
The second deadline became 2030 — the year by which all hospital buildings that don’t meet the standards should be replaced entirely to meet the Alquist structural and non-structural standards (referring to the ability to stay fully functional).
The problem, as hospital operators see it, involves the industry’s collective ability to meet SB 1953’s deadlines. Much progress has been made, especially in the expanding Sacramento Valley, where the growing population is relatively affluent and government employment produces a relatively stable market for healthcare.
“There will be, frankly, very few hospitals that will be able to meet
the deadlines.”
— Sen. Dave Cox
New hospital facilities are going up at a fast rate among the four hospital operators in the Sacramento area: Kaiser Permanente, Sutter Health, Catholic Healthcare West and UC Davis.
Some hospitals have made significant progress on their upgrades, and the rest say meeting the deadlines is not realistic. Resolving the question of how to help the latter achieve compliance is up in the air, because there isn’t much consensus on anything, even within the hospital industry.
It was in the 1970s, following the Sylmar quake, that Mike Kimmel started working as a carpenter with the family business. Kimmel Construction was performing hospital work then, as it does now. Its niche involves smaller projects: the remodels and additions that allow hospitals the space and power capabilities to upgrade to the latest technology, and offer the services — like single-patient rooms, and continually larger ones at that — that are expected in an advancing industry.
“We do it because not everybody can,” Kimmel says. “It’s a market that we have an ability to service. And the satisfaction that comes with completing a hospital project successfully is tremendous.”
Kimmel became company president this year, taking over from his father, Jack Kimmel. Not least among the problems of hospital work, he says, is that it’s difficult to keep a healthcare facility functioning when there’s construction going on.
“There are very strict requirements any time we conduct work in a hospital,” Kimmel says. “There’s dust control, infection control and fire protection to think about. You get inside the ceilings of these places, and there’s not much room to work in. It’s very time consuming, it’s very difficult, and the costs have gone up significantly over the past five years or more.
“We’ve staffed up and prepared for the increase in work.”
— John Gillengerten, deputy director, OSHPD
“The big concern is that all of this work will need to be completed by 2030,” Kimmel continues, “and if you’ve ever done hospital work — even the smallest project on a hospital — it’s amazing how long it takes to get through the process. I’m not trying to say [the regulatory process] is inappropriately long, but it’s very time-consuming.”
Part of the problem, Kimmel says, is that SB 1953 doesn’t allow leeway for varying degrees of earthquake danger across the landscape. And the biggest problem at this point, he says, is that there are far more questions than answers regarding solutions, and little agreement.
“Everybody needs to sit down and talk about it and come up with a plan,” he says. “I would say there’s good progress being made. In a general sense, stricter seismic standards are a good idea. But let’s get together and do it in a way [that works for everyone].”
The dramatic rise in construction costs was the main thrust of a study commissioned by the California Health Care Foundation and released in January that assessed the feasibility of California’s hospitals meeting the deadlines of SB 1953.
Those costs have risen 63 percent over three years, and the industry is facing a bill of $200 million to meet SB 1953’s original 2008 deadline and its five-year extension, granted by lawmakers in 2000. The report, conducted by the Rand Corp., also brings up the aspect of unfairness by introducing the idea of public subsidies to the process now, with years past and deadlines looming.
It has been, after all, 13 years since the passing of SB 1953, and a decade since its requirements were laid out in specific detail. Creating subsidies now raises the question of fairness with respect to those hospitals that have already performed work toward meeting the deadlines.
“We know there are a limited number of construction firms that are doing this kind of work,” says Sen. Dave Cox of Roseville. “We know that construction costs have gone up 66 percent. There will be, frankly, very few hospitals that will be able to meet the deadlines” of SB 1953.
Cox also awaits the reassessment of the seismic risks of the state’s various regions. “I certainly believe that we ought to prioritize the hospitals [based on seismic regions], but that can be done administratively,” Cox says.
Meanwhile, Cox introduced a bill that became law this year. It adds one more extension to the SB 1953 deadlines — a two-year extension past 2013 for specific hospital projects, providing construction is under way and good-faith efforts demonstrated.
The idea of such deadline extensions has seen opposition from the California Nurses Association and the Service Employees International Union. Cox complains of “monkey business” on the part of those who oppose deadline extensions, and he’s hoping for debate on hospital seismic regulations to soon spark up in the Capitol again. He was hoping the Rand report would serve that purpose. But as of February, Cox said attention hadn’t started turning that way yet. “In this building, things are done on an incremental basis,” he lamented in his Capitol office.
Another law passed last year was SB 167, introduced by Sen. Jackie Speier of San Mateo. It allows for the reassessment of seismic conditions and damage risk. The last earthquake on record that brought any significant damage to the Sacramento Valley happened in 1892. Centered near Vacaville and measuring in the mid-sixes on the Richter scale, that quake caused some collapsing of structures.
“I’m not trying to say the regulatory process is inappropriately long,
but it’s very time-consuming.”
— Mike Kimmel, president, Kimmel Construction
There are faults around the Sacramento area, the coastal range and the foothills, and faults still being discovered, and although it hasn’t happened in recent memory, damaging seismic activity does occur in the valley from time to time. But exactly how damaging, with respect to modern construction methods?
One loud complaint about SB 1953 is that it doesn’t apply a scale of standards, given the widely varying susceptibilities to earthquake damage among the state’s various regions. So there’s currently a re-measuring project going on using new seismic risk-analysis software called Hazards U.S., or HazUS.
With HazUS — the use of which is allowed by Speier’s bill — the state’s hospital grounds are being measured individually for susceptibility to earthquake damage. The data achieved could result in some buildings being reclassified out of the worst category of structural integrity, helping to ease deadline pressure. And the collected data should help point the legislature to the best solutions, says Jan Emerson, spokeswoman for the California Hospital Association. “I think right now, people are kind of holding off on a legislative level to see what comes out of the HazUS software.
“There’s not one best solution. It’s going to take a number of things,” Emerson says. “The solution may be, in some cases, give them a few years. It may be financing; it may have to be a combination of things.
“Once the HazUS is done, then we’re going to have to figure out which is the worst of that group. It’s called ‘worst first.’ And then we’ll know, do they need financing, do they need time, or both?”
Many hospitals date back to the ’40s, ’50s, ’60s and ’70s, and the lifespan of a hospital building is 40 to 60 years, Emerson says, meaning there’s a whole crop of buildings ripe for replacement. Of the 2,700 hospital buildings among California’s 430 hospitals, about 1,000 have been classified in SB 1953’s lowest category, Structural Performance Category 1, at high danger of collapsing in an earthquake.
“We have foreseen this and added quite a bit of staff,” says John Gillengerten, acting deputy director of facilities development at the Office of Statewide Health Planning and Development. “We have also been able to contract some of the plan review to private firms. So we’ve staffed up and prepared for the increase in work.
“[Hospitals] hold a special place in society,” Gillengerten continues. “They are one of the factors that make society resilient.”
Philippe Taquin, director of facility services at Methodist Hospital of Sacramento, a Catholic Healthcare West property, complains of the high hurdles raised by SB 1953. But he expresses understanding of the opposite perspective, as others do.
“On the other side of the fence, it forces people to promote safe hospitals, and I like that,” Taquin says. “They understand [at OSHPD], and they are helping us comply with code requirements. They are in the same boat we are.”
What price progress?
A few years ago, before the Sylmar earthquake struck Southern California and sparked the state’s new era of seismic standards, hospitals didn’t look the way they do now.
Leading up to the 1970s, hospitals generally contained wards — large rooms containing a number of beds, thus making efficient use of hospital space.
But what about the greater likelihood of spreading disease in that arrangement? What about privacy issues? Even efficiency may not be what it seems: beds might often sit empty even while they’re needed because they sit in gender-specific wards.
“That is no longer the way healthcare is delivered,” says Jan Emerson, spokeswoman for the California Hospital Association. “Just as far as an infection-control perspective, separate rooms are the way to go.”
And even since single-occupancy became standard, the rooms have grown to accommodate modern technology, which requires more space next to each bed. And those progressing standards aren’t being offset by the fact that, with today’s technology, outpatient care is much more prevalent than it was just a few years ago.
“Even though you may be having fewer beds, the square footage is the same or larger than it used to be,” Emerson says. It’s the constant state of the hospital facilities: change. The industry keeps growing, and standards of care and service move forward.
That’s been a big factor in pushing the cost of hospital construction to $1,000 per square foot, some of the building industry’s most expensive. And with building costs rising sharply in recent years, it’s difficult for hospitals to know how much cash they’ll need five years in the future.
Meanwhile, two-thirds of California’s hospitals, the CHA says, are losing money. “You also have to consider that half of the hospitals in California are operating in the red,” Emerson says. “A lot of those hospitals are not credit-worthy and cannot borrow money to do this.”
There’s also high demand for the limited number of architects, engineers and builders qualified for work that meets state seismic standards. The cost of financing has risen, and hospitals face the time-consuming processes of land acquisition for new buildings, which are necessary for meeting SB 1953’s 2030 deadline — and, in the long run, more cost-effective than retrofitting.
During seismic-related construction, a hospital needs to accommodate altered parking on the outside of its buildings, and altered patient accommodations on the inside.
“When SB 1953 was enacted, it was believed that you could relatively inexpensively go in and retrofit buildings, then build new ones later on,” Emerson says. “[But] it’s shown to be much more expensive.
“In the middle of all this, what you have to keep in mind is that it’s a balancing act. You can’t treat patients in a building being retrofitted. And you can’t close down and re-open four years later.”
