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General Hospital & Trauma Center
SPUR Hospital Renewal Task Force
Report on SB 1953 and Hospital Renewal


I. Hospital Planning & SB1953

Hospitals around the state of California are working to meet the requirements of California Senate Bill (SB) 1953, passed in 1994 as an amendment to the Alquist Seismic Safety Act of 1983. The law is in direct response to the 1994 Northridge earthquake, which damaged many hospitals, several severely enough to require temporary closures and eventual replacement. Nearly all the damage was in buildings constructed prior to 1973. The focus of SB1953 is bringing these older hospitals up to current seismic standards, or replacing them, and unlike the original 1983 legislation (which had similar goals but no timeline) it mandates a strict set of deadlines for hospitals to meet these enhanced requirements.


SB 1953 required hospitals to meet progressively higher levels of seismic safety beginning in January 2002. The Structural Performance Categories (SPC) levels of seismic safety range from SPC-1 (buildings pose a significant risk of collapse and a danger to the public after a strong earthquake) to SPC-5 (buildings are in compliance with the structural provisions of the Alquist Act). A separate rating for Non-structural Performance Categories (NPC) levels of seismic safety, which regulate a building’s non-structural systems including communications, power supplies, and emergency lighting follow the same five point scale. Under SB 1953, hospitals must meet the following schedule for improvement or risk closure:

  • January 2002 meet NPC-2 standards (minimum life safety)
  • January 2008 meet SPC-2 and NPC-3 standards (intermediate standard)*
  • January 2030 meet SPC-4 and NPC-5 standards (ultimate standard)

*An extension to 2013 can be granted if a hospital chooses to rebuild its acute care facility rather than seismically strengthen an existing building.


Under state law, hospitals needed to submit an evaluation to the state by January 2001, including a compliance plan to meet the enhanced standards. Based on the results of those submissions, it is now estimated that SB1953 affects 470 hospitals in California. If all of those beds are eventually replaced to meet the enhanced requirements, the total cost (at $1 million/bed) could total 41 billion dollars.


The role of the State
There is no centralized hospital planning at the state or regional level. No official body tells a hospital how and where a hospital should be built, whom it should serve, and what services it should include. The state, through the Office of Statewide Health Planning and Development (OSHPD) does work as a very specialized state equivalent to a building inspection department. They license hospitals and inspect plans and facilities against very strict criteria. But OSHPD does not have a mandate to plan for the entire statewide hospital system. This is not to say that the state does not have a very strong role in hospital policy through various financial support mechanisms for health care, including the Medi-Cal program. However, the state has a limited role in facilitating a coordinated response of hospitals, cities, and regions to the impact of SB1953. In fact, centralized planning of any sort is made more difficult by the restraints of the Sherman Antitrust Act, which enjoins hospitals from having any discussions which could divide up the market. At the same time, the State preempts local governments in health care regulation, and, because funding for services is largely from the State, it controls how services are provided to a large extent.


There is no state funding currently available to meet the enhanced seismic requirements of SB1953. Rather, hospitals are left to fund the required work by raising private capital (in the case of private systems) or through the passage of general obligation bonds (public systems). In an economically stressed and very quickly changing health care environment, these institutions (public, non-profit, and for-profit) are under great pressure to make the right billion dollar decisions.


II. SB1953 and San Francisco Hospitals
San Francisco, as an older urban center, has many hospitals that predate current seismic standards. When state mandated analysis was completed in 2001, it showed that many of San Francisco’s hospitals (or portions of hospitals) are rated the lowest possible rating, SPC-1. Of San Francisco’s twelve licensed, and ten active acute-care hospitals (not counting the VA Hospital, which as a federal facility is not subject to state law), only Kaiser (Geary Campus), Chinese Hospital, and the UCSF Parnassus Campus are ranked SPC 2 or greater. Three quarters of the hospitals (and licensed beds) do not meet current state standards, and have acute care facilities that will need to be substantially retrofitted or replaced to meet 2008 or 2013 deadlines. The total bill for the retrofit? More than $2 billion dollars.


San Francisco Hospitals

SPC Ratings1

Total Beds2

SUTTER HEALTH

California Pacific Medical Center

California Campus

1

95

Pacific Campus

1

311

Davies Campus

1

255

   

    

   

St. Luke's Hospital

1

147

   

  

  

Catholic Healthcare West

       

     

St. Francis Memorial Hospital

1

293

St. Mary's Medical Center

1

397

  

  

  

Chinese Hospital

3

59

   

  

  

Kaiser Foundation Hospital

    

   

Geary

2

323

French 3

1

193

  

  

  

San Francisco General Hospital

1

403

   

     

   

UCSF

   

   

Parnassus

2 (Moffit)

579

Mount Zion 3

1 (B building)

298

      

      

3353

TOTAL LICENSED BEDS

   

2392

TOTAL LICENSED BEDS AT SPC-1

   

(71%)

   

   

    

TOTAL ACTIVE LICENSED BEDS

   

2802

TOTAL ACTIVE LICENSED BEDS AT SPC-1

   

1901

   

   

(68%)

Notes:

  • The number noted is the lowest Structural Performance Rating received by the hospital. Since hospitals are usually an amalgam of different structures built over time, the lowest rated structures may be only a portion of the entire facility, with significant implications for the total cost required to retrofit.
  • Total beds licensed by the state. The count has little relation to active beds, as is clear from fact that several hospitals that are no longer active are still listed in the state database.
  • Not currently an acute care hospital

Source: California Office of Statewide Health Planning and Development
The local impact of SB1953
The seismic standards of SB1953 are coming on top of a wave of consolidations and closures in San Francisco’s hospitals, as the industry reacts to changes ranging from the impact of managed care to advances in technology and to changing demographics. The private system in San Francisco has consolidated into three main groups: Kaiser, Catholic Healthcare West, and Sutter (which has separate affiliations with CPMC and St. Lukes). Tiny Chinese Hospital is the only unaffiliated private hospital left.


Even with consolidations and closures, it remains unclear whether San Francisco needs all of its remaining hospital capacity. Hospital capacity is usually counted in beds, and there are two ways to count the bed supply: licensed and available. Licensed beds reflect the physical number of beds licensed with the state. This number is far greater than the number of beds in use, however, as many licensed beds have been converted to medical offices or other uses, and in some hospitals entire floors are permanently closed down while remaining "licensed". A more accurate count of bed supply is the facilities that are actually staffed.


SB 1953 presents hospitals with the opportunity to reconsider their ideal size and configuration. Because many of the hospitals are now parts of systems rather than stand alone facilities, it also allows for multi-campus planning. For instance, California Pacific is preparing a master plan for its three campuses; this effort was instigated in part by SB1953, and also by the desire to rationalize its system in a very competitive health care environment.


The role of the City and County of San Francisco
The City and County of San Francisco has a limited role vis a vis SB1953. No entity within city government is looking comprehensively at the entire hospital system’s reaction to SB1953. Rather, the city is looking at private institutions plans on a case by case basis, and is focused primarily on the future of San Francisco General Hospital.


The Department of Public Health is responsible for ensuring the health and safety of all San Franciscans, with a special emphasis in ensuring that services are vital and appropriate for San Francisco’s poor and uninsured, who have extremely limited options for care outside the San Francisco General and the Community Health Network of neighborhood clinics. Although the poor and uninsured are the primary "market", the City also provides the only trauma center (for all severe accident victims) in the city, and it provides mental health, epidemiology, disease control and other programs for the entire population. The Department’s primary response to SB1953 has been focused on planning to rebuild SF General to meet state requirements by the 2013 deadline. The regulation of non city-supported institutions is largely beyond the purview of the Department of Public Health.

Each medical institution requires an Institutional Master Plan, and many are updating these plans (for the first time in many years) as SB1953 leads them to consider fundamental changes to their facilities. These plans, reviewed (but not approved) by the Planning Commission, look primarily at site and environmental issues, and are therefore fairly limited in pertinence to the issue of location, because they do not currently present an opportunity for review of the entire hospital and health care system.


III. Location issues for San Francisco Hospitals
The location of San Francisco hospitals are directly related to historic settlement patterns of the city. Hospitals are located near the dense core of San Francisco, clustered in or near the northeast quadrant of the city. Importantly, there are no hospitals located in the Avenues (with the exception of the VA hospital which is not accessible to the general public). There are also only two hospitals south of Market Street, and none south of the Mission district. However, because San Francisco is a small city geographically, and because hospitals are located in the densest residential neighborhoods, the majority of the population has good access to hospital facilities. As hospitals consolidate, the access to those that remain becomes more at issue.


It’s important to qualify why access to hospitals is important, and what the impact of diminished access would be. The most critical location issue concerns emergency services, when minutes could make the difference between life and death. Emergency rooms can only exist, legally and by current medical practice, within full acute care hospital settings, therefore the consolidation and closure of hospitals can have a substantial impact on access to emergency rooms. For most other services, location is not a critical issue, but is rather one of convenience for hospital patients and visitors.


The varying missions and services of different hospitals can result in different locational needs for each facility. For example, UCSF Medical Center specializes in complex tertiary care, and the institution views its location on a regional and not simply local basis. San Francisco General’s trauma center, likewise, serves a regional market, but most other services the hospital has a primary market area of the east side of the city. The way the institutions look at locational criteria can therefore be very different from how an outside observer of the entire hospital system would look at the same issue.


Location Criteria for future SB1953 projects
In trying to assess the impact of hospital moves, consolidations, and reconstruction on the city, the SPUR hospital renewal task force felt that we needed a set of location principles. These principles allow us to judge whether the responses of hospitals to SB1953 are in the interests of the city as a whole. These location principles describe an ideal hospital system. In a city in which the location of hospitals is largely fixed to real estate currently owned by the hospitals, the location criteria are not meant to dictate moves to "better" locations, but to ensure that current locations work as best they can to meet the needs of all San Franciscans. The following are common-sense location principles adopted by the committee for hospitals:

  • Locate with close attention to seismic risk
  • Locate close to the majority of people to be served, so as to minimize access problems.
  • Locate so that both hospitals and their emergency and trauma services are distributed throughout the city for fastest access by residents.
  • Locate to minimize parking and traffic impact on neighborhoods
  • Locate to maximize public transit access, particularly for workers, visitors, and outpatients.
  • Locate near freeway access from the north, south and east for ideal regional access.
  • Locate a helicopter landing pad as a part of an overall emergency network

Further Location Criteria for Hospital Sites
In addition to the macro level criteria for acute hospital location, the SPUR Hospital Task Force also addressed the ideal site conditions for new hospital development. In addition to being good criteria for new sites, these criteria are useful in considering how hospitals prioritize the use of land and buildings they currently own, because under SB1953 they may need to tear down and rebuild significant portions of their infrastructure. Because all existing sites have substantial constraints, however, it is unlikely that any would meet the ideal criteria presented here, although these criteria can form the basis for a critique of plans as they are developed.


Site Principles:

  • The site is adequate for both the short and long term, meaning that the site will be able to accommodate over time a staged full replacement of the initial buildings so that a future relocation is unnecessary.
  • The site is substantial enough to permit the optimum number of patient beds per floor, to facilitate staffing flexibility.
  • The site can accommodate appropriate parking
  • The area around the site is zoned to accommodate support services complementary to hospitals (pharmacies, medical offices, etc) so that as few as possible need to occupy the main site
  • The site is designed so that there can be floor to floor relationships among its individual structures
  • The site can be designed to produce a healing environment for patients, preferably with an outdoor view from patient rooms and outdoor access to gardens or parks.
  • The site is free of environmental risks to its patients, staff and neighbors.

The most serious issue any of the existing hospitals face in a very dense urban setting is the ability to develop flexible efficient buildings that can change over time. Creative solutions to this site problem are needed at all sites, even such a tabula rasa as Mission Bay. Mission Bay appears to meet or nearly meet all of these site considerations on first glance, although as part of a new neighborhood, the development of a completely new hospital would also require development of (and zoning for) all of the support services that surround hospital facilities. Since a hospital was not a part of the Mission Bay plan and its Environmental Impact Report, this is a major planning issue for UCSF Medical Center, Catellus, the Redevelopment Agency, and the city as a whole.


Location Criteria and Current Hospital Plans
Several planning processes underway are considering location as a variable. Most importantly, UCSF Medical Center is considering whether to stay at its current Parnassus location, or perhaps move all or a portion of its inpatient activities to Mission Bay and/or Mount Zion in newly developed hospital facilities. After initial study, it appears that UCSF Medical Center may adopt a one hospital or a two-hospital replacement model, which could use one or a combination of Parnassus, Mt. Zion or Mission Bay as sites. Since UCSF Medical Center only operates one acute care hospital with full emergency access currently, any two-hospital solution including Parnassus would result in better access in the future, so long as both replacement hospitals offered emergency services. However, any option that results in the closure of the hospital at Parnassus would be a significant concern. As the closest hospital to the Southwest quadrant of the city, closure could create a problem for emergency access from areas like the Sunset.


SF General is also planning to respond to SB1953 with a plan to rebuild their acute care facility. The City is considering moving SFGH to Mission Bay with UCSF, and through their Long Range Service Delivery Planning Project has established that as their preliminary recommendation for SFGH’s rebuild. In terms of our locational criteria, the move is within the same general area of the city, and should not raise major issues. A move to Mission Bay could result in somewhat better transit access with the new 3rd Street light rail line and augmented bus transit along 16th street, as well as more direct freeway access. Importantly, it’s possible that a helipad could be located in Mission Bay to serve SF General’s trauma center (the only trauma center in the city). Trauma centers are required to have helicopter access and SFGH is now operating under a temporary waiver from this requirement. However, this potential is very speculative, with only preliminary talks with UCSF Medical Center. If SFGH does move their inpatient hospital to Mission Bay, their current Potrero campus would retain many of the ambulatory care and psychiatric facilities currently housed there.


Opening a new hospital at Mission Bay would increase options for people living on the city’s east side, where most of the city’s population growth is taking place and where freeway access is good. The seismic stability of Mission Bay is a nagging concern, however. Buildings built there would, of course, be built to the highest seismic standards, but care must also be taken to assure that access ways to and from Mission Bay will survive any large earthquake in the future. Access from most of the City is across two bridges at Mission Creek and a level grade crossing of Caltrain. These are all potential hazards.


Timing is a critical issue for SFGH. The City believes that it must make a decision about location by next January in order to meet the 2013 deadline for rebuilding, which may be too soon for UCSF’s decicion-making process which is on a longer time schedule.


All of the other hospital systems are currently planning to solve SB1953 issues in place, on very restricted urban sites. The system which is contemplating the greatest change is California Pacific Medical Center, which has the luxury of using their three campuses to stage work to meet the state’s deadlines. Their current plan calls for the construction of a new acute care hospital on the California campus, the Pacific Campus would be redeveloped as an ambulatory care center, and the Davies campus would house continuum-of-care services, such as skilled nursing and rehabilitation. By 2013, when this plan would be fully implemented, California Pacific would have a rationalized network of health centers. In what has become a lightning rod for neighborhoods and the city, however, they could eventually provide only one emergency room, at the California Campus.


Catholic Healthcare West currently plans to continue to operate both St. Mary’s and St. Francis, believing that both can be upgraded fully to meet SB1953 requirements without closure. St. Lukes, which has just recently entered into affiliation with Sutter Health, has a relatively minor retrofit of approximately $15 million dollars to meet current requirements..


Aside from Mission Bay, there are no other new hospital locations in serious discussion. Despite the relative lack of service in the western and southern quadrants of the city, there is neither the obvious availability of land, nor is there the financial capacity and desire on the part of any hospital group or other sponsoring agency.


IV. Ambulatory Care Considerations
The location of ambulatory care was discussed by the Committee as it relates to the rebuild of acute hospital facilities.


Ambulatory care encompasses primary care and procedures and labs that are, broadly, "walk-in, walk-out" and don’t require an overnight stay. Some ambulatory care, such as individual doctors offices, were traditionally scattered but have tended to consolidate in hospital-affiliated group practices under managed care. At the same time, technological advances have allowed for more and more medical procedures to take place outside of hospital settings, some in doctors offices, some in clinics. The location of ambulatory care may therefore be at hospital sites, near hospital sites, or at other sites entirely.


In general, from the patient perspective, ambulatory care centers are most convenient when they are located near home locations or near work locations (which may well be part of a hospital complex). In an ideal health care system, those facilities that patients use most often would be dispersed throughout neighborhoods. In cases where hospitals are vertically integrated, there may be countervailing tensions to keep ambulatory care facilities close to or on hospital property in order to more effectively manage and staff the facilities.


The relationship of ambulatory care to the hospital rebuild is a significant one, because existing hospital real estate is finite and constricted. In programming a rebuild for acute care facilities, hospitals are forced to take a careful look at all of the facilities on their campuses. It is possible that through the process of site master planning virtually mandated by SB1953, hospitals may find it possible to disperse some ambulatory care to less expensive locations (and in less expensive construction) off-campus, rather than rebuilding it as a part of an acute-care complex. This may have the side benefit of also increasing the geographic dispersion of ambulatory care. We urge hospitals to look at this issue closely, and not to assume that all services currently in hospitals necessarily need to remain there.


An importantly related issue is that a significant portion of the uninsured population uses hospital emergency rooms for their urgent care needs due to a lack of reasonable alternatives, and any thoughtful alternatives to facilitate moving this demand to less expensive offsite centers could save providers money. There is currently no easy solution to this problem, but it will require fundamental changes in the way medical service is provided and paid for.


A model that other cities have begun to use is to locate clinics adjacent to other services such as fitness centers, pharmacies, adult day care, etc. This can provide more comprehensive services in neighborhoods and can also tailor the services to the special needs of the neighborhood populations. The City is looking at the role of their 11 neighborhood clinics and we suggest that they consider such co-locations with partnering with other public or private providers. The private hospitals should also consider this model.


V. Conclusions
The public must be involved in the planning processes that are currently underway, because the decisions that will be made by institutions, both public and private, will affect the public’s access to medical care. The hospitals have commendably involved nearby neighborhood groups in reviewing the physical and program aspects of their projects. The San Francisco Department of Public Health has also undertaken a very important planning process for the future of the San Francisco General and the Community Health Network, and is involving a wide stakeholder group in that process.


However, all of these separate planning processes are taking place in a vacuum of sorts, because they are all taking place simultaneously, and one effort cannot therefore be well informed of what will happen to other institutions. There is little time for iterative planning. A perfect illustration of that problem is in the UCSF/SFGH Mission Bay decision. Although there is talk of co-location, the barriers to achieving integration - while the planning process hurtles toward key decisions - are high to say the least.


The Role of the State
The State has an important role in mediating the impact of SB1953 through reconsideration of the timeline and scope of the rebuild process. Although no one wants to delay the provision of safe hospitals, we also don’t want to force closure of facilities without adequate planning for replacements. Time is already short to meet the 2008 deadlines for compliance, and appropriate recognition could allow time for more coordinated planning. The State also must consider the impact of a single deadline on the ability to review a great number of projects at one time, not to mention the concurrent needs for engineering, architectural, and construction services. We have seen the impact of just one large constructio project, the San Francisco Airport on the availability and cost of steel, for example.


If the state is imposing the substantial requirement of SB1953, we believe they also have the responsibility to help fund reconstruction, and through funding guide the process sufficiently to ensure that San Franciscans remain well served by hospitals in accessible locations.


The Role of the City
The City should continue to plan for the provision of health care to all of its citizens, and in particular its least fortunate residents. The future role of San Francisco General Hospital is thus of paramount concern. We would encourage the City to continue to coordinate with UCSF, and enhance that collaboration wherever possible, to plan for the optimal public system in San Francisco. We also encourage the city to take into account the actions of other institutions, and to collaborate with them to the greatest extent allowed by law. The Department of Public Health should, in our view, embrace the broad view that the health of the entire city is a part of their purview and should examine and comment on the plans of other providers when they affect the availability of health services to the entire city.


It’s possible that the Institutional Master Planning process could also present options for the city to have a more proactive role in planning with institutions, rather than simply reacting to plans. While the Planning Commission only reviews, and does not adopt Institutional Master Plans, it is certainly possible that they could request additional information that would be useful in understanding the plans of the institutions, such as a total bedcount of both licensed and in-use beds and major services provided, and contemplated. As part of their review of the Institutional Master Plans, the City should require of each institution a professionally performed survey of existing cultural, architectural and historical resources so that the hospitals can develop their plans with this knowledge and the Planning Commission and its staff can react to proposals with the understanding of the value of all the existing facilities to the community as a whole. The Institutional Master Plan process also affords the City the opportunity to include into the health care conversation issues related to neighborhood impact, transit and traffic planning, and the disposition of cultural, architectural and historical resources.


Role of SPUR
SPUR’s role in the current hospital planning process is modest, but is hopefully helpful to the process. We seek to provide a citywide perspective, informed by individuals with many different viewpoints and backgrounds. We believe that this broad perspective is a valuable addition to the debate.

  • We will continue to provide a forum for health care institutions, interest groups, and the public at large to learn about and discuss hospital planning, and thus enhance communication between parties.
  • We can help the public learn more about the challenges presented by SB1953 through our newsletter, forums, and op ed pieces.
  • We can raise issues to public agencies and elected officials if we feel there might be a better policy alternative. Our traction is limited in this topic because many of the solutions to the problems raised by SB1953 lie at the state level. Necessarily, our policy analysis of SFGH rebuild alternatives will be our most direct and important opportunity to comment on public policy.