Should We Retrofit our Buildings or our Healthcare System?

By  |  October 31, 2007 | 

Last night, my house shook for 10 seconds or so in a 5.6 earthquake. I’ve felt a couple of dozen of them since moving to San Francisco in the mid-80s. When the rumbling begins, the thought chain is always interesting. It goes like this:

  1. Initial Thought: Hey, is that an earthquake, or is the subway going by?
  2. Seconds 2-4: Oh yeah, the subway is more than a mile away.
  3. Seconds 5-7: So it must be an earthquake.
  4. Second 8: Wow, that’s pretty cool.
  5. Second 9 and Beyond: I’m not 100% sure I’m not about to die (this stage ends either when the quake stops or you’re dead).

That’s what happened last night (I’d just entered Stage 5 when it stopped). Turned out to not be The Big One, things settled down, the dogs stopped barking, the kids went back to whatever it is that they do when they’re supposed to be doing their homework, and I returned to my chronic state of denial regarding the risks of living on a fault line.

The California State Legislature has been worrying for me, though. In 1994, in the wake of the Northridge quake that suspended services at 23 hospitals and caused $3 billion in hospital damage, they passed a law mandating that hospitals come up to seismic snuff by 2008 (this was later delayed till 2013) or close. By 2030, all hospitals must be able to continue full operations, not just remain standing, after a quake.

By coincidence, an interesting article in this week’s Modern Healthcare [may require a subscription] describes the challenges hospitals are facing as they gear up to comply with this earthquake law. A RAND/California HealthCare Foundation study estimated the statewide costs of the retrofits to be over $100 billion. The Modern Healthcare piece describes a new FEMA risk-modeling software (hope it wasn’t used pre-Katrina) that assesses seismic risk more charitably. The software may (it’s still up in the air whether the state will allow its use) let some hospitals partly off the retrofitting hook. 

With this uncertainty, hospitals are complaining about not knowing whether they should begin or cancel billions of dollars in construction projects. Some hospitals got a temporary reprieve last month when the Governator signed a bill that grants a 7-year extension (till 2020) to safety net hospitals. But, FEMA software and extensions aside, it is pretty clear that this work is going to have to get done eventually.

This is not a theoretical issue for me. At this moment, I am looking out my window at the Golden Gate Bridge – scratch that, actually it is a poster of the Golden Gate Bridge, since my spectacular 9th story view north is obscured by scaffolding for the next year. Why? Turns out the building I’m sitting in is a hospital, with real patients, and (whew) it meets the 2013 earthquake standards. But (tiny problem here) the building it is attached to does not. Some brainy engineer figured out that if the building that is located three feet from me – on the other side of my wall – fell down, my building probably would too.

So the two buildings are being sawed apart. All 15 floors. Even as we speak. Cost: $36 million. And my view.

But, enough petty whining from me. Let’s turn to the larger question: Is this a reasonable mandate?

Well, no. In the past century, fewer than 100 hospitalized patients have died in California earthquakes (or because they were injured and hospitals weren’t able to treat them). According to the IOM Report estimates, approximately 100 people will die of preventable medical errors in California hospitals this week. For $100 billion, we could computerize every hospital and physician office in California, use the remaining money to provide health insurance to every man, woman, and child in the state, and have a few bucks left over for Springsteen tickets [these estimates are all pro-rated for California’s share of the U.S. population].

Now, of course, some of the expenditures really are mandatory because the buildings are crumbling and just plain need to be replaced. But a mandate like this, drawn up by agitated legislators before the dust of a big quake has settled to earth, is a formula for warped priorities.

The bottom line is that this is not how one would spend $100 billion on California hospitals if your goal was to improve health and save lives. So, I say, let’s rethink the earthquake law and spend the money in areas that will give us far more bang for the buck.

And this from a man who spent part of last night shaking it up.


  1. Bob Wachter November 16, 2007 at 6:20 pm - Reply

    A quick update from today’s Modern Healthcare IT Strategist e-newsletter, in an article entitled “Calif. hospitals catch a break on quake safety”, written by by Rebecca Vesely/ HITS staff writer:

    “California hospitals have gotten a reprieve on upcoming seismic safety deadlines, potentially saving them $4 billion in construction costs.

    A state commission ruled unanimously that hospitals could use new computer software, called HAZUS—short for Hazards U.S.—to more accurately assess how vulnerable their buildings are to collapse or damage during an earthquake than previous estimates.

    Developed by the Federal Emergency Management Agency, HAZUS calculates risk in a variety of natural disasters. The California agency that oversees the hospital construction projects, the Office of Statewide Health Planning and Development, has set guidelines for the software’s use.

    The agency estimates that 50% to 60% of 1,110 hospital buildings statewide required to meet a seismic-safety deadline of 2013 could be reclassified at a lower risk of collapse and not need to be rebuilt until 2030. The rest of the buildings will still need to meet the 2013 deadline or face closure, and many of those construction efforts are already under way or completed. The total cost of hospital reconstruction in the state, paid for by the hospitals, could reach $110 billion.”

  2. Bob Wachter December 12, 2007 at 4:50 am - Reply

    Another update: the Governator just signed another reprieve — giving hospitals that can demonstrate “financial hardship” till 2020 to meet the standards (this is on top of the 2030 deadline for hospitals that became less risky after using the HAZUS tool). Haven’t looked over the fine print yet to see what’s involved in proving hardship, but I am guessing that a lot of hospitals are going to try to qualify.

    Some Hospitals Win Reprieve on Deadlines for New Construction

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About the Author: Bob Wachter

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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