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General Hospital & Trauma Center

Civil Grand Jury Report
San Francisco General Hospital

OVERVIEW
San Francisco General Hospital (SFGH) is the only trauma center for all San Franciscans, is the Bay Area's regional trauma center, and is the primary acute care hospital for the uninsured, underinsured, and indigent citizens of San Francisco.


SFGH does not meet California seismic codes; failure to comply with these codes will result in the closure of SFGH by 2008. This must not be allowed to happen; SFGH should be rebuilt.


SFGH and the University of California at San Francisco (UCSF) have a symbiotic relationship, i.e., in return for research space and opportunities, UCSF physicians staff the hospital. This relationship with UCSF is essential if SFGH is to continue to provide the best possible health care to all San Franciscans. The relationship must be maintained as each entity pursues its respective plan for the future of its acute care facility.


To save SFGH, the Mayor, Board of Supervisors, and citizens must act quickly to obtain the funding necessary to build a new hospital. They must encourage SFGH and UCSF to continue to work together to maintain their relationship, and to finalize swiftly their respective plans so that a site for SFGH can be determined. These actions will ensure that the region's only trauma center stays open and that the citizens of San Francisco are assured of retaining this important acute care hospital.


BACKGROUND
SFGH is the only trauma center (See Attachment 1) in San Francisco and one of only two in the Bay Area. SFGH also serves as a regional referral center for patients in need of trauma services. SFGH's mission statement calls for "the provision of quality services that treat illness, promote and sustain wellness and the prevention of the spread of disease, injury and disability." SFGH serves a large percentage of the uninsured population. As of December 2000, the Department of Public Health (DPH) estimated that 135,000 San Franciscans were uninsured. DPH stated that "the majority of residents without health insurance are employed (full or part-time) or are members of families with working adults." [Annual Overview of Health in San Francisco, DPH 2001]


Section 17000 of the California Welfare and Institutions Code requires San Francisco to provide health care services to indigent and poor persons. SFGH is the primary provider of health care services to the City's indigent population.


SFGH has a 23-acre campus, consisting of 13 buildings, the oldest of which was built in 1915. The main acute care hospital is comprised of two structures built in 1974.


California Senate Bill (SB)1953, passed in 1994 as an amendment to the Alfred E. Alquist Seismic Safety Act of 1983 (See Attachment 1), requires existing hospitals to meet progressively higher levels of seismic safety beginning in January 2002. The Structural Performance Categories (SPC) levels of seismic safety under this act range from SPC-1, the lowest possible structural performance category (wherein buildings pose a significant risk of collapse and a danger to the public after a strong earthquake), to SPC-5, the highest category (wherein buildings are in compliance with the structural provisions of the Alquist Act and are reasonably capable of providing services to the public following strong ground motion). Buildings rated SPC-2 do not significantly jeopardize life, but may not be repairable or functional following strong ground motion. The Non-structural Performance Categories (NPC) levels of seismic safety -- which regulate a building's non-structural systems, including communications, emergency power supplies, bulk medical gas, fire alarms, and emergency lighting -- range from NPC-1 (basic systems essential to life safety and patient care are inadequately anchored to resist earthquake forces) to NPC-5 (wherein the buildings meet all criteria). In buildings rated NPC-2, essential systems vital to the safe evacuation of the building are adequately braced. The required time frames under the Alquist Act are.

  • 1/1/02 -- hospitals must meet a minimum of NPC-2 or no longer provide acute care services
  • 1/1/08 -- hospitals must meet a minimum of SPC-2 and NPC-3 or no longer provide acute care services*
  • 1/1/30 -- hospitals must meet SPC-4 and NPC-5 or no longer provide acute care services.

*An extension to 2013 may be granted if a hospital can demonstrate that the area it serves would suffer a diminished health care capacity (such an extension may be approved at any time prior to 1/1/08 [See Attachment 1]). In its compliance plan submitted to the State, SFGH indicated that it plans to apply for such an extension.


It takes 10 years to build a new hospital in California (San Francisco Business Times, 2/15/02)


SFGH is rated SPC-1 and NPC- 2 as of 01/01/02. All other San Francisco hospitals, except Chinese Hospital and Kaiser Hospital, are also rated SPC-1. Sources at DPH, the Office of Statewide Health Planning and Development (OSHPD) and the California Health care Association (CHA) state that non-compliance with SB1953 will most likely result in the closure of one, two, or three acute care hospitals in San Francisco between now and 2013, with a concomitant loss of beds.


SFGH is staffed with physicians from UCSF. In return, SFGH provides research opportunities and facilities to UCSF physicians/researchers at the SFGH campus.
The "red brick buildings" on the SFGH campus -- where most research is conducted -- are not seismically safe. Officials at UCSF and SFGH stated that the University of California Regents have decreed that, by 2008, UC researchers may conduct their research only in seismically safe facilities.


The Master Plan Concepts for SFGH to Meet Seismic Safety Mandates (September 28, 2001) estimates that the cost to build a new, conforming building by 2013 is $550 million and the cost for retrofitting $1.05 billion. 


INVESTIGATIVE PROCESS
The San Francisco Civil Grand Jury (CGJ) interviewed staff from --

  • San Francisco Health Commission
  • Department of Public Health
  • San Francisco General Hospital
  • Emergency Medical Services
  • Community Health Network
  • University of California at San Francisco
  • San Francisco Chamber of Commerce
  • San Francisco Medical Society
  • Service Employees International Union, Local 790
  • California Department of Statewide Health Planning and Development
  • California Health care Association
  • Bay Area private engineering and architectural firms

CGJ reviewed the following documents --

  • The Alfred E. Alquist Hospital Facilities Seismic Safety Act of 1983
  • Senate Bill (SB)1953 (passed by the State legislature in September 1994)
  • California Welfare and Institutions Code (pertinent sections)
  • OSHPD Summary of Seismic Performance Ratings, 4/00
  • American Institute of Architects California Council's Guidelines for SB 1953
  • SFGH Rebuild Planning Committee's Information Manual
  • SFGH SB 1953 Seismic Evaluation Report OSHPD Submittal, 12/15/00
  • Annual Overview of Health in San Francisco, DPH 2000
  • The Master Plan Concepts for SFGH to Meet Seismic Safety Mandates, 9/01
  • Leading the Way to a Healthier Community, SFDPH's Strategic Plan, 12/00
  • CHA Special Report, 10/00 &4/01
  • City and County of San Francisco Trauma Care System Plan 2001
  • Rand Report: Estimating the Compliance Costs of California SB 1953, 8/01
  • CHA Report "Hospital Seismic Compliance - A Framework for Responsible Action to Earthquake Readiness, 11/99
  • News articles in numerous local and national newspapers

FINDINGS AND RECOMMENDATIONS
FINDING 1
Three buildings within the SFGH complex are rated SPC-1: the main acute care hospital, the out-patient/clinical laboratory, and the central power plant. Those buildings must (1) be rebuilt, (2) be retrofitted, or (3) cease to provide or be involved in the direct provision of hospital services after 2008 (or 2013 if an extension is granted). Should SFGH cease to provide hospital services to its citizens, State law requires San Francisco to contract out for those services with other licensed and compliant, acute care facilities.
CGJ interviewed --

  • staff from San Francisco General Hospital
  • staff from the University of California at San Francisco
  • staff from the San Francisco Department of Public Health
  • staff from the Community Health Network
  • staff from the San Francisco Health Commission
  • members of the San Francisco Medical Society
  • members of the California Health Care Association
  • members of the San Francisco Chamber of Commerce
  • members of Bay Area architectural and engineering firms
  • members of SEIU local 790 (health care workers)
  • representatives of the Office of Statewide Health Planning and Development

Without exception, all persons interviewed indicated unequivocally that SFGH should be rebuilt.

RECOMMENDATION 1
REBUILD SAN FRANCISCO GENERAL HOSPITAL
. The existence of SFGH to ensure the delivery of the best possible health care -- such as acute care services, trauma care, and wellness -- is essential to the overall quality of life in San Francisco. Rebuilding SFGH's acute hospital facilities, rather than the other available options, not only serves to maintain the highest level of health care for San Francisco citizens, but also, is the most cost-effective solution to providing those required services. CGJ takes no position regarding where or how SFGH should be rebuilt.


Required Responses -
Board of Supervisors -- 90 days
Health Commission -- 60 days
Office of the Mayor -- 60 days

FINDING 2a
Although a master planning process, as it relates to the seismic-safety mandate, was started for the SFGH campus, San Francisco does not have a current master plan for SFGH that takes the impact of SB1953 into consideration or that maps out all contingencies and alternatives. The most recent Master Plan is dated 1987.


FINDING 2b
Due to the anticipated closure of one or more privately owned hospitals in San Francisco, as well as new State regulations for nurse-staffing ratios, it is almost a certainty that San Francisco will face the loss of a substantial number of hospital beds in the near future. This will increase the already high incidence of emergency-room diversions, as well as seriously exacerbate the existing bed shortage in San Francisco. Additionally, ongoing international incidents and the threat of bio-terrorism have heightened awareness of the need for an appropriate infrastructure to improve emergency preparedness.


Representatives of CHA, OSHPD, and Bay Area architectural and engineering firms, as well as the San Francisco Business Times (February 15, 2002), have stated that it takes a minimum of 10 years to design, approve, fund, and construct a new hospital.


The CGJ could find no evidence that San Francisco has adequately planned a bond issue to implement the financing required for SFGH to comply with SB1953. Interviews and discussions with representatives of DPH and with others indicate that "political considerations" are significantly impacting the decision of when to introduce a bond measure for funding the construction of a new hospital. DPH staff is sanguine about obtaining voter approval of a bond measure for the SFGH rebuilding project; they have indicated that they cannot envision possible voter rejection of what may be the largest bond measure yet presented to citizens of San Francisco. 


RECOMMENDATION 2a
In order to take appropriate actions to implement the State's seismic safety mandates, San Francisco should complete a master plan for SFGH.

Required Response -
             Health Commission -- 60 days

RECOMMENDATION 2b
QUICKLY DEVELOP A SHARED VISION AND INTRODUCE A BOND MEASURE
that will have the greatest chance of voter approval. All involved parties -- the Mayor, Board of Supervisors, Health Commission, Director of Public Health -- must develop a shared vision for San Francisco's health care needs, including the location and configuration of services and the role SFGH will play in meeting those needs. This must be concluded expeditiously so that the financial impact and the appropriate form and amount of financing for rebuilding SFGH may be determined. If a bond is required, the type should be determined. If voter approval is required, the measure should be placed on the ballot at the earliest possible time -- this will permit necessary adjustments and re-introduction should voters fail to approve it. Creative alternative financing, including a revenue bond, should be considered. CGJ strongly encourages all appointed and elected officials to put politics aside to ensure that adequate time and money are available for completion of the construction prior to the legislated deadline (which, with an approved extension, is 2013, at the latest). CGJ is concerned about the implied assumption of San Francisco officials that all extensions will be approved. This could place in peril the continued existence of SFGH.

Required Responses -
Board of Supervisors -- 90 days
Health Commission -- 60 days
Office of the Mayor -- 60 days

FINDING 3
Both SFGH and UCSF Hospital must comply with SB1953. Because of the renown of UCSF, SFGH is able to attract internationally recognized physicians and researchers to staff its hospital, thereby providing the highest quality health care to the citizens of San Francisco.


It is the consensus of all persons interviewed at UCSF, SFGH, DPH, the San Francisco Medical Society, the San Francisco Chamber of Commerce, members of SEIU local 790, and members of the CHA, that, regardless of the method of compliance with SB 1953, the relationship between SFGH and UCSF must be maintained. 


RECOMMENDATION 3
MAINTAIN THE MUTUALLY BENEFICIAL SFGH-UCSF AFFILIATION
. As SFGH goes forward with its plans to rebuild, it must consider seriously the requirements and needs of UCSF as they relate to research, facilities, access to patients, and compliance with UC regents' policy.

Required Response -
          Health Commission -- 60 days

FINDING 4
To rebuild SFGH, funding must be approved by the citizens of San Francisco. Many citizens may not be aware of the extent to which SFGH serves the general population. While the hospital does provide services to the indigent and uninsured populations, it also serves the rest of the City and the Bay Area through its trauma center. It is, in fact, every citizen's hospital. 


RECOMMENDATION 4
EDUCATE THE PUBLIC ON THE ROLE OF SFGH IN THE COMMUNITY.
Mount a public service campaign to inform the citizens of San Francisco of the significance of SFGH and its trauma center in our midst.

Required Responses -
Board of Supervisors -- 90 days
Health Commission -- 60 days
Office of the Mayor -- 60 days

Summary of Required Responses -
         
         Board of Supervisors -- Recommendations 1,2b, and 4
         Health Commission -- Recommendations 1, 2a, 2b, 3, and 4
         Office of the Mayor -- Recommendations 1, 2b, and 4

 ATTACHMENT 1 -- TERMINOLOGY
An ACUTE CARE HOSPITAL is defined as one which renders medical treatment to individuals whose illnesses or health problems are of a short term or episodic nature.


LEVEL 1 TRAUMA CENTER is defined as an institution that "must provide 24 hours a day/7 days a week trauma, surgical and emergency services." It is the highest designation available for trauma centers and signifies an institution that: cares for a high volume of seriously injured patients (at least 1,000 per year), provides in-house surgical staff and all necessary specialists who are immediately available, provides training and education for health professionals in trauma care and maintains a program for trauma research.


DIMINISHED HEALTH CAPACITY as defined in the California Health and Safety Code section 130060(a): "After January 1, 2008, any general acute care hospital building that is determined to be at potential risk of collapse or pose significant loss of life shall only be used for non-acute care hospital purposes. A delay in this deadline may be granted by the office upon a demonstration by the owner that compliance will result in a loss of health care capacity that may not be provided by other general acute care hospitals within a reasonable proximity." Implementing regulations for OSHPD (Part 1, Title 24) state:


1.5 Delay in Compliance


1. After January 1, 2008, any general acute care hospital which continues acute care operation must be at a minimum of an SPC 2 facility as defined in Article 2, Table 2.5.3 or shall no longer provide acute care services.


2. The Office may grant the hospital owner a delay to Section 1.5.1 if compliance will result in diminished health capacity which cannot be provided by other general acute care hospitals within a reasonable proximity.


2.1 Hospital owners seeking a delay must submit a written request to the Office including a statement with supporting documentation regarding the reason for noncompliance with subdivision 1.5.1and a schedule indicating when compliance will be obtained. A delay request and compliance schedule may be submitted simultaneously with the hospital's evaluation and compliance plan pursuant to the requirements of this article. If a delay request is submitted after the seismic evaluation report, compliance plan and schedule, the request must include an amended compliance schedule and must be submitted to the Office no later than January 1, 2007.


2.2 The time extension for compliance shall be granted in one year increments, up to a maximum of five (5) years, beyond the mandated year of compliance. The facility requesting the extension shall provide evidence of efforts to implement an approved Compliance Plan which may include design/construction contracts and schedules which demonstrate efforts to implement the compliance measures within the requested period of extension.


SB 1953 OVERVIEW - Passed in 1994, SB1953 is an amendment to the Alfred E. Alquist Seismic Safety Act of 1983 (See Attachment 1). It was enacted in the wake of the 1994 Northridge earthquake which caused significant damage to health care facilities in California. SB1953, and implementing regulations promulgated by OSHPD, prescribe new architectural and engineering standards for acute care hospitals. "With the intent of ensuring that all general acute care hospitals in California will be reasonably capable of providing services to the public after a seismic event, SB1953 requires that by January 1, 2030, all licensed general acute care hospitals in the State of California must be compliant with the Hospital Facilities Seismic Safety Act.


"SB1953 mandates specific seismic evaluation procedures which all licensed general acute care hospital facilities must use to determine their respective structural and nonstructural performance categories. Upon completion of the structural and non-structural evaluations, and after determination of the appropriate performance categories, all general acute care hospitals must then formulate a compliance plan that shall indicate the hospital's intent to do any of the following with their non-complying facilities:

  • Retrofit for compliance with SB1953 for continued acute care operation beyond the year 2030;
  • Partial retrofit for initial compliance, with closure or replacement planned by the years 2002, 2008 and/or 2030;
  • Remove from licensed acute care service with conversion to non-acute care health facility use;
  • No action - Building to be closed, demolished or replaced." [AIA California Council Guidelines to SB 1953]

Seismic evaluation, determining the structural performance category (SPC) and submitting compliance plans to OSHPD were among the first steps in the process. The SPC system rates the risk of the building structural frame and ranges from SPC-1 through SPC-5. SPC-1 is the highest risk rating. All building systems must be evaluated as well (the NPC or "non-structural performance category", again ranging from NPC-1 through NPC-5, with NPC-1 being the highest risk rating).

GLOSSARY

CGJ = (San Francisco) Civil Grand Jury
CHA = California Health care Association
DPH = Department of Public Health
NPC = Non-structural Performance Categories
OSHPD = Office of Statewide Health Planning and Development
SB = (California) Senate Bill
SFGH = San Francisco General Hospital
SPC = Structural Performance Categories
UCSF = University of California at San Francisco