Any opinions, findings, conclusions, or recommendations expressed in this publication do not

necessarily reflect the views of FEMA. Additionally, neither FEMA or any of its employees makes

any warrantee, expressed or implied, or assumes

any legal liability or responsibility for the accuracy,

completeness, or usefulness of any information,

product, or process included in this publication.

Users of information from this publication assume

all liability arising from such use.
Acknowledgements

Principal Authors:

Frederick Krimgold, Virginia Tech Center for Disaster

Risk Management, Virginia Polytechnic Institute and

State University

David Hattis, Building Technology Incorporated

Melvyn Green, Melvyn Green & Associates Inc.

Contributors:

Milagros Kennett, FEMA, Project Officer, Risk

Management Series Publications

John Harrald, GWU

Charles Scawthorn, ABS Consulting

Medhi Setareh, VT

Rene Van Dorp, GWU

William Whiddon, BTI

Project Advisory Panel:

Daniel Abrams, University of Illinois

Daniel Butler, National Retail Federation

John Coil, John Coil Associates

Joseph Donovan, Carr America

James Harris, National Multi Housing Council

Randal Haslam, Jordan School District, Utah

James Malley, Degenkolb Engineers

Mike Mehrain, URS Dames & Moore

Anthony Moddesette, UC Davis Medical Center

Lawrence Reaveley, University of Utah

Technical Review:

Chris Poland, Degenkolb Engineers

Daniel Shapiro, SOHA Engineers

Production:

Lee-Ann Lyons and Amy Siegel, URS Group, Inc.

Contents

Contents

Executive Summary........................................................................................... i

Foreword ........................................................................................................... iii

Preface .............................................................................................................. iv

Introduction ...................................................................................................... vi

How to Use This Manual ............................................................................... viii

PART A Critical Decisions for Earthquake Safety in

Hospitals ....................................................................................... A-1

A.1 Is There an Earthquake Hazard for Your Hospitals?................ A-1

A.2 Are Your Hospital Buildings Safe? ........................................... A-3

A.3 What Can Be Done to Reduce Earthquake Risk in

Existing Vulnerable Hospital Buildings? ................................. A-5

A.4 Incremental Seismic Rehabilitation of Existing

Hospital Buildings ................................................................... A-6

PART B Planning and Managing the Process for Earthquake

Risk Reduction in Existing Hospital Buildings ........................ B-1

Introduction ..................................................................................... B-1

B.1 Integrating the Efforts of Facility Management, Risk

Management, and Financial Management .............................. B-2

B.2 Integrating Incremental Seismic Rehabilitation into

the Facility Management Process ........................................... B-3

B.2.1 A Model of the Facility Management Process

for Existing Hospital Buildings ................................... B-3

B.2.2 Elements of an Incremental Seismic Rehabilitation

Program ...................................................................... B-3

B.2.2.1 Due Diligence Analysis ................................ B-4

B.2.2.2 Seismic Screening ....................................... B-4

B.2.2.3 Seismic Evaluation ...................................... B-5
Incremental Seismic Rehabilitation of Hospital Buildings

B.2.2.4 Emergency Management Planning for

Accreditation ............................................... B-5

B.2.2.5 Developing a Risk Reduction Policy ............ B-6

B.2.2.6 Seismic Rehabilitation Planning for

Specific Buildings ........................................ B-6

B.2.2.7 Staging Seismic Rehabilitation

Increments................................................... B-9

B.2.2.8 Budget Packaging ...................................... B-10

B.2.2.9 Bond Packaging ......................................... B-10

B.2.2.10 Seismic Rehabilitation Project

Management.............................................. B-11

B.2.3 Integration into the Hospitals Facility

Management Process ............................................... B-11

B.3 Opportunities for Seismic Risk Reduction in Support of

Integrating Incremental Seismic Rehabilitation into the

Facility Management Process................................................ B-12

B.3.1 Responding to Occupant Concerns .......................... B-13

B.3.2 Emergency Management/Response Planning .......... B-13

B.3.3 Emergency Management/Mitigation Planning ......... B-14

B.3.4 Developing a Risk Reduction Policy ......................... B-14

B.3.5 Incorporating Federal and State Mandates and

Programs .................................................................. B-14

B.3.6 Coordinating with Risk and Insurance Managers ..... B-14

B.3.7 Becoming Familiar with Applicable Codes ............... B-15

B.3.8 Establishing and Maintaining a Roster of Design

Professionals ............................................................ B-15

B.3.9 Negotiating Code Enforcement ................................ B-15

B.4 Preparing a Plan for the CEO and the Board ........................ B-16

B.4.1 Getting Started ........................................................ B-16

B.4.2 Getting Started Plus ................................................. B-16

B.4.3 Getting Started with a Jump Start............................ B-16

B.5 Additional Components of a Comprehensive

Earthquake Safety Program .................................................. B-17

B.5.1 Building Contents Mitigation .................................... B-17

B.5.2 Earthquake Drills ...................................................... B-17

PART C Tools for Implementing Incremental Seismic

Rehabilitation in Existing Hospital Buildings ......................... C-1

Introduction ..................................................................................... C-1

Guide to Sections C.1 and C.2 ........................................................ C-1

C.1 How to Use Engineering Services ........................................... C-2

Seismic Screening and Evaluation.......................................... C-2

Incremental Seismic Rehabilitation Planning and Design ...... C-2

Construction Period Support ................................................... C-3

Continuity of Building Documentation.................................... C-3
Contents

Fees for Professional Services ................................................ C-3

C.2 Discovering Integration Opportunities for Incremental

Seismic Rehabilitation ............................................................ C-4

Introduction ............................................................................ C-4

Categories of Maintenance and Capital Improvement

Projects ................................................................................... C-4

Work Descriptions and Matrices of Seismic Performance

Improvement Opportunities ................................................... C-5

Definitions of Seismic Performance Improvements ................ C-7

C.2.1 Patient Care Improvements ....................................... C-8

C.2.2 New Technology Accomodation................................ C-10

C.2.3 Fire and Life Safety Improvements .......................... C-12

C.2.4 Roofing Maintenance and Repair/Re-roofing ............ C-14

C.2.5 Exterior Wall and Window Maintenance/Façade

Modernization........................................................... C-16

C.2.6 Underfloor and Basement Maintenance

and Repair ................................................................ C-18

C.2.7 HVAC Improvements ................................................ C-20

C.2.8 Energy Conservation/Weatherization/

Air Conditioning........................................................ C-20

C.2.9 Hazardous Materials Abatement .............................. C-21

C.2.10 Definitions of Seismic Performance

Improvements .......................................................... C-22

Appendix. Additional Information on Hospital

Facility Management ......................................................... App-1

Introduction: Typical Facility Management for Hospitals ...... App-1

1. The ACQUISITION Phase of Hospital Facility

Management ..................................................................... App-2

2. The Current Building USE Phase of Hospital Facility

Management ..................................................................... App-4

3. The ACCREDITATION Phase of Hospital Facility

Management ..................................................................... App-7

4. The PLANNING Phase of Hospital Facility

Management ..................................................................... App-9

5. The Maintenance and Rehabilitation BUDGETING

Phase of Hospital Facility Management .......................... App-12

6. The Maintenance and Rehabilitation FUNDING

Phase of Hospital Facility Management .......................... App-14

7. The Maintenance and Rehabilitation

IMPLEMENTATION Phase of Hospital Facility

Management ................................................................... App-15

i

Executive Summary

Earthquakes are a serious threat to hospital safety and

pose a significant potential liability to hospital administrators and healthcare organizations. Hospital buildings in 39 states are vulnerable to earthquake damage.

Unsafe existing buildings expose healthcare organizations to the following risks:

 Death and injury of patients, doctors, nurses, and

staff

 Damage to or collapse of buildings

 Damage to and loss of furnishings, equipment, and

other building contents

 Disruption of patient care and other hospital operations

 Loss of an indispensable community resource

The greatest earthquake risk is associated with existing hospital buildings

that were designed and constructed before the use of modern building

codes. For many parts of the United States, this includes buildings built as

recently as the early 1990s.

Although vulnerable hospital buildings need to be replaced with safe, new

construction or rehabilitated to correct deficiencies, for some healthcare organizations new construction is limited, at times severely, by budgetary constraints, and seismic rehabilitation is expensive and disruptive. However,

incremental seismic rehabilitation, an innovative approach that phases

in a series of discrete rehabilitation actions over a period of several years, is

an effective, affordable, and non-disruptive strategy for responsible mitigation action. It can be efficiently integrated into ongoing facility maintenance

and capital improvement operations to minimize cost and disruption. The

Executive Summary
Incremental Seismic Rehabilitation of Hospital Buildings

ii

strategy of incremental seismic rehabilitation makes it possible to get started

now on improving earthquake safety in your healthcare organization.

This manual provides healthcare organizations with the information necessary to assess the seismic vulnerability of their buildings and to implement a

program of incremental seismic rehabilitation for those buildings. The

manual consists of three parts:

Part A, Critical Decisions for Earthquake Safety in Hospitals, is for

healthcare organization senior executives, board members, hospital directors, vice presidents for facility management, and other policy makers who

will decide on allocating resources for earthquake mitigation.

Part B, Planning and Managing the Process for Earthquake Risk Reduction in Existing Hospital Buildings, is for hospital facility managers,

risk managers, and financial managers who will initiate and manage seismic

mitigation measures.

Part C, Tools for Implementing Incremental Seismic Rehabilitation in

Existing Hospital Buildings, is for facility managers, or others responsible

for facility management, who will implement incremental seismic rehabilitation programs.

To get the most out of this manual:

 Communicate the importance of assessing your organization’s risks

and pass this manual on to the staff members responsible for

facility management, risk management, and financial planning.

Specify that they develop an analysis of the current seismic risk of

your buildings and a strategy for risk reduction.

 Promptly initiate a program of earthquake risk reduction in your

organization’s buildings located in an earthquake-prone zone that

were not designed and constructed to meet modern building codes.

 Consider incremental seismic rehabilitation as a cost-effective

means to protect the buildings and, most importantly, the safety of

patients, doctors, nurses, and staff, because it is a technically and

financially manageable strategy that minimizes disruption of

hospital operations.
iii

Foreword

The concept of seismically rehabilitating buildings in discrete segments, as

resources become available or as part of a structural renovation program,

was pioneered by the Federal Emergency Management Agency (FEMA) and a

Virginia Polytechnic Institute/Building Technology Inc. team that, in the early

1990s, published Existing School Buildings – Incremental Seismic Retrofit

Opportunities, FEMA 318. Lack of resources at the time, however, restricted

application of this promising concept to a few states in the Pacific Northwest

and to a single occupancy or use category: schools. FEMA is now pleased to

make available a manual on hospitals. Further, the team is also preparing a

series of manuals that will address seven additional building uses: schools

(an updated version), retail establishments, multi-family dwellings, office

buildings, emergency management facilities, warehousing/distribution centers, and hotels/motels. A separate manual will serve the needs of design

professionals and building officials and will be applicable across all occupancy categories.

FEMA gratefully acknowledges the dedicated efforts of all members of the

team: the Virginia Polytechnic Institute and State University (the prime contractor); the Project Advisory Panel; Project Consultants; Building Technology

Inc.; EQE Inc.; Melvyn Green & Associates Inc.; the Institute for Crisis Disaster

and Risk Management of the George Washington University; and URS Group,

Inc. The FEMA Project Officers add their sincerest appreciation for the excellent support of this multi-disciplinary team.

The Federal Emergency Management Agency

Foreword
Incremental Seismic Rehabilitation of Hospital Buildings

iv

Preface

This manual is intended to assist healthcare organization personnel responsible for the funding and operation of existing hospital facilities across the

United States. This publication and its companion documents are the products of a Federal Emergency Management Agency (FEMA) project to develop

the concept of incremental seismic rehabilitation—that is, building modifications that reduce seismic risk by improving seismic performance and that are

implemented over an extended period, often in conjunction with other repair,

maintenance, or capital improvement activities.

The manual was developed after the project team analyzed the management

practices of healthcare organizations located in various seismic zones in different parts of the United States. It focuses on the identified concerns and

decision making practices of hospital managers and administrators.

This manual is part of a set of manuals intended for building owners, managers, and their staff:

 Incremental Seismic Rehabilitation of School Buildings (K-12),

FEMA 395

 Incremental Seismic Rehabilitation of Hospital Buildings,

FEMA 396

 Incremental Seismic Rehabilitation of Office Buildings,

FEMA 397

 Incremental Seismic Rehabilitation of Multifamily Apartment

Buildings, FEMA 398

 Incremental Seismic Rehabilitation of Retail Buildings,

FEMA 399

 Incremental Seismic Rehabilitation of Hotel and Motel Buildings,

FEMA 400

 Incremental Seismic Rehabilitation of Storage Buildings,

FEMA 401

 Incremental Seismic Rehabilitation of Emergency Buildings,

FEMA 402
v

Each manual in this set addresses the specific needs and practices of a particular category of buildings and owners, and guides building owners and

managers through a process that will reduce earthquake risk in their building

inventory. The manuals answer the question, as specifically as possible:

“What is the most affordable, least disruptive, and most effective way to reduce seismic risk in existing buildings?” By using the process outlined in

these manuals, building owners and managers will become knowledgeable

clients for implementing incremental seismic rehabilitation specifically

geared to their building use category.

In addition to this set of manuals, there is a companion manual, Engineering

Guideline for Incremental Seismic Rehabilitation, FEMA 420. It is intended to

assist architects and engineers who provide services to building owners and

contains the information necessary for providing consulting services to owners for implementing incremental seismic rehabilitation. Architects and

engineers using that handbook will be effective consultants serving a knowledgeable owner. Together they will be in a position to implement an effective

incremental seismic rehabilitation program.

Preface
Incremental Seismic Rehabilitation of Hospital Buildings

vi

Introduction

Hospitals, Risk, and Liability

Healthcare organizations face a wide array of risks.

These risks range from malpractice to fire. Risk

management for hospitals typically is driven by

experience; we recognize the need for professional malpractice insurance and for sanitary precautions in food services, but the risk of

catastrophic loss due to a damaging earthquake is

more difficult to understand or to anticipate. Earthquakes are low-probability high-consequence

events. Though they may occur only once in the

life of a building, they can have devastating, irreversible consequences.

Moderate earthquakes occur more frequently than

major earthquakes. Nonetheless, moderate earthquakes can cause serious damage to building contents and nonstructural building systems, serious

injury to occupants and staff, and disruption of

building operations. Major earthquakes can cause

catastrophic damage including structural collapse

and massive loss of life. Those responsible for

hospital safety must understand and manage

these risks, particularly risks that threaten the lives

of patients, doctors, nurses, and staff.

Earthquake risk is the product of hazard exposure

and building vulnerability, as shown in the following equation:

RISK = HAZARD x VULNERABILITY

To manage earthquake risk in existing hospital

buildings, one must understand the earthquake

hazard and reduce building vulnerability.

This manual is designed to give decision makers

the framework and information for making inYou may be liable for earthquake

deaths and injuries in your older

hospital buildings.

The 1933 Long Beach, California, Earthquake

destroyed at least 70 schools and damaged 420

more, 120 of them seriously. As a direct response, California enacted the Field Act, which

established strict design and construction standards for new schools in California. But what

about all the existing schools that were vulnerable to earthquakes? It took over 30 years to

solve this problem, but more than just the passage of time was required.

In 1966 the Attorney General of California

issued an opinion indicating that school boards

were responsible for ensuring non-Field Act

buildings were examined, and if schools were

found to be unsafe and the board did not make

the necessary corrections to make them safe,

the individual school board members were personally liable. The opinion received widespread

media attention. School boards, then realizing

the gravity of the situation, became quite concerned about the structural condition of their

pre-Field Act public school buildings. Legislative

action soon followed. The Governor signed the

Greene Act in 1967, which relieved the individual school board members of personal liability only once the board initiated the process of

examining existing buildings and established an

intent to carry through to completion all the

steps necessary for their replacement or repair.

This responsibility may apply to hospital

building owners as well. You too may be liable

for earthquake deaths and injuries in your older

buildings, but can you wait 30 years to act? This

manual provides you with the tools to assess

your vulnerability and to find cost-effective

ways to reduce your liability today.
vii

formed decisions about investing in earthquake risk management measures.

It is structured to follow the decision making process of existing planning

and management practices and will help you evaluate financial, safety, and

healthcare priorities.

Healthcare organizations may vary greatly in size, wealth, and technical capability. Nevertheless, they are all government regulated and subject to accreditation, and have, as a result, comprehensive long-term facility management,

maintenance, and development plans. The successful implementation of improved earthquake safety should be part of a comprehensive approach to

building safety and multi-hazard mitigation.

Failure to address earthquake risk leaves the healthcare organization exposed

to potential losses, disruption, and liability for deaths and injuries. While purchasing insurance may protect the organization from financial losses and

liability, it still leaves it susceptible to disruption as well as deaths and injuries. Only building rehabilitation can reduce losses, deaths, and injuries, as

well as control liability and disruption. However, single-stage seismic rehabilitation can be expensive and disruptive. Incremental seismic rehabilitation

can reduce that cost and disruption.

Considering Incremental Seismic Rehabilitation

The incremental rehabilitation approach to seismic risk mitigation focuses on

improvements that will decrease the vulnerability of hospital buildings to

earthquakes at the most appropriate and convenient times in the life cycle of

those buildings. The approach clarifies, as specifically as possible, what is the

most affordable, least disruptive, and most effective way to reduce seismic

risk in your buildings.

Prior to initiating a program of incremental seismic rehabilitation, a

healthcare organization must first address the following three questions:

 Are your hospital buildings located in a seismic zone?

 Are these buildings vulnerable to earthquakes?

 What can you do to reduce earthquake risk in existing vulnerable

buildings?

This manual will help you find the right answers.

Introduction
Incremental Seismic Rehabilitation of Hospital Buildings

viii

How to Use This Manual

Critical Decisions: Healthcare organization senior executives, board members, hospital directors, and similar policy makers should read Part A. Section

A.1 provides a general understanding of the earthquake hazard faced by a

healthcare organization. Section A.2 provides an overview of how the seismic

vulnerability of hospital buildings and resultant losses can be estimated. Section A.3 provides an overview of the actions a healthcare organization can

take to reduce earthquake risk, including incremental seismic rehabilitation.

Section A.4 details how to implement the concept of incremental seismic

rehabilitation, including the additional benefits of integrating incremental

seismic rehabilitation with other maintenance and capital improvement

projects. By understanding these four sections, the healthcare

organization’s top management can establish a policy of seismic

risk reduction and initiate a more specific, objective, and cost-effective program of incremental seismic rehabilitation by its technical

staff.

Program Development: Those responsible for a healthcare organization’s

facility, risk, and financial management should read Parts A and B, paying

particular attention to Part B. Sections B.1 through B.3 provide detailed guidance on how the initiation of a program of incremental seismic rehabilitation can fit into the ongoing facility management process used

by the healthcare organization, and indicates specific activities you can undertake. A separate Appendix, Additional Information on Hospital Facility

Management, is provided at the end of this manual for those seeking more

information on hospital facility management. It contains a discussion of the

specific phases of the facility management process and activities for

healthcare administrators seeking further detail.

Project Implementation: Healthcare organization and hospital facility managers should read Part C in addition to Parts A and B. Section C.1 provides

guidance on using the consulting services of architects and engineers in

implementing a program of incremental seismic rehabilitation. Section C.2

discusses specific opportunities for combining increments of seismic

rehabilitation with other maintenance and capital improvement

projects. A companion manual for design professionals has been developed

to provide technical guidance for the detailed design of specific rehabilitation

projects.
A-1

Part A

A

Critical Decisions for

Earthquake Safety

in Hospitals

For Healthcare

Organization Senior

Executives, Board

Members & Hospital

Directors

A.1 Is There an Earthquake Hazard for Your

Hospitals?

Earthquakes are one of the most serious natural hazards to which healthcare organizations may be exposed. Although hospital administrators face a variety

of risks to occupant safety and operations that may

appear more immediate, the consequences of earthquakes can be catastrophic. Therefore, despite the fact

that earthquake occurrences are rare, earthquake

safety should be given full consideration in design and

investment for risk management and safety.

The first step to understanding earthquake risk:

RISK = HAZARD x VULNERABILITY

is to learn the likelihood and severity of an earthquake affecting your

buildings.

The Earthquake Hazard: Where, When, and How Big

The surface of the earth consists of solid masses, called tectonic plates, that

float on a liquid core. The areas where separate plates meet each other are

called faults. Most earthquakes result from the movement of tectonic plates,

and seismic hazard is strongly correlated to known faults. A map of zones of

seismic hazard for the United States, based on maps provided by the U.S.

Part

In Brief

 Geographic location is the most

significant factor

of seismic hazard.

 Soil conditions at

a particular site

also influence the

seismic hazard.
Incremental Seismic Rehabilitation of Hospital Buildings

A-2

Geological Survey (USGS), shows three zones from the lowest, green, to the

highest, red. The white areas have negligible seismic hazard.

The USGS earthquake hazard map is based on a complex assessment of expected seismic activity associated with recognized faults. The scientific understanding of earthquakes continues to improve and has resulted in increased

estimates of seismic hazard in various parts of the country over the last decade.

Hospital administrators responsible for the safety of patients, doctors,

nurses, and staff need to know whether to be concerned about earthquakes.

Some guidelines for determining earthquake risk in your location are:

 If your hospital is located in a red zone on the map

Earthquakes are one of the most significant risks facing your facilities.

 Take immediate action to undertake comprehensive vulnerability

assessment. Professional structural engineers should perform this

assessment.

 Identify and either replace or rehabilitate vulnerable existing

buildings as soon as possible.

 If your hospital is located in a yellow zone

The probability of severe earthquake occurrence is sufficiently high to

demand systematic investigation of your buildings.

 Assign responsibility for investigation to the risk managers and

facility managers within the organization. If they are not available,

seek professional engineering assistance from outside.

 Identify vulnerable buildings and schedule them for replacement,

rehabilitation, or change of use.

Seismic

Hazard

Map
A-3

Part A

 Also consider mitigation of nonstructural hazards, such as securing

equipment and suspended lighting that could injure building

occupants in an earthquake.

 If your hospital is located in a green zone

 Consider low-cost mitigation strategies that protect building

occupants and your investment in facilities and systems, even

though the probability of an earthquake is low.

Beyond this broad seismic zone designation, expected earthquake ground

motion at a particular location is further influenced by local geology and soil

conditions. Geotechnical engineering studies should be done to understand

fully the earthquake hazard at a particular site in red and yellow zones.

A.2 Are Your Hospital Buildings Safe?

The second step to understanding earthquake risk:

RISK = HAZARD x VULNERABILITY

is to learn the expected damage and losses that could result from an

earthquake.

What Happens to Hospital Buildings in Earthquakes

Earthquake fault rupture causes ground motion over a wide area. This ground

motion acts as a powerful force on buildings. Buildings are principally designed to resist the force of gravity, but resistance to earthquake forces requires specialized earthquake engineering. Horizontal earthquake forces

cause rapid movement of the foundation and displacement of upper levels of

the structure. When inadequately designed to resist or accommodate these

earthquake forces, structures fail, leading to serious structural damage and,

in the worst case, total building collapse.

In addition to ground motion, buildings may suffer earthquake damage from

the following effects:

In Brief

 Seismic vulnerability depends on

structural type,

age, condition, contents, and use of

hospital buildings.

 Hazard exposure

and building vulnerability may result in

substantial death,

injury, building and

content damage,

and serious disruption of healthcare

operations.

1 A wave on the surface of a lake or landlocked bay caused by atmospheric or seismic

disturbances.

Fault rupture under or

near the building, often

occurring in buildings

located close to faults.

Reduction of the soil

bearing capacity under

or near the building.

Earthquake-induced

landslides near the building.

Earthquake-induced

waves in bodies of water

near the building (tsunami, on the ocean and

seismic seiche1

 on lakes).
Incremental Seismic Rehabilitation of Hospital Buildings

A-4

Building Age and Earthquake Vulnerability

The first earthquake design legislation was enacted in 1933 for schools in

California (the Field Act). Earthquake design requirements were established

for hospitals in California in 1973 (the Alfred E. Alquist Hospital Seismic

Safety Act). Since that time, awareness of earthquake risk has expanded

across the country, and building codes have been improved because of research and experience. Since the early 1990s, most new hospitals in the

United States have been constructed in accordance with modern codes and

meet societal standards for safety. However, older hospital buildings should

be reexamined in light of current knowledge. Some seismically active parts

of the country (the Midwest) have only recently adopted appropriate seismic

design standards, and in other parts of the country (the Northwest) estimates

of seismic risk have been revised upward. The serious problem resides in

existing vulnerable hospital buildings constructed without seismic requirements or designed to obsolete standards. The building code is not retroactive; there is no automatic requirement to bring existing buildings up to

current standards. Safety in existing buildings is the responsibility of the

owner/operator. That means you!

Estimating Building Vulnerability

It is possible to estimate roughly the vulnerability of a healthcare

organization’s portfolio of buildings and to identify problem buildings with a

technique called “rapid visual screening.” Healthcare organizations can produce generalized estimates of expected damage in the initial seismic risk

assessment of its buildings.

Engineers have defined levels of the damage that can be expected in particular types of buildings due to varying intensities of earthquake motion. These

levels of damage range from minor damage, such as cracks in walls, to total

building collapse. In addition to building type, expected damage is also a

function of building age and the state of maintenance. Hospitals suffering

from deferred maintenance will experience greater damage than well-maintained hospitals will. For example, failure to maintain masonry parapets significantly increases the possibility of life-threatening failure in even a

moderate earthquake.

After initial rapid screening, specific seismic risk assessment for individual

hospital buildings requires detailed engineering analysis.

Other Earthquake Losses

While a serious concern in its own right, building failure is the direct cause of

even more important earthquake losses:

 Death and injury of patients, doctors, nurses, and staff

 Destruction of hospital contents and equipment

 Disruption of the delivery of all patient care services, including the

capability to provide emergency services in a disaster

The expected extent of these losses can also be estimated based on hazard

and vulnerability assessments.
A-5

Part A

A.3 What Can Be Done to Reduce Earthquake Risk

in Existing Vulnerable Hospital Buildings?

Failure to address earthquake risk leaves the healthcare

organization exposed to potential losses, disruption,

and liability for deaths and injuries.

While purchasing insurance may protect healthcare organizations from financial losses and liability, it still leaves them exposed to disruption as well as

deaths and injuries. Only building rehabilitation can reduce losses, deaths,

and injuries and control liability and disruption.

The implementation of seismic risk reduction through building rehabilitation

will primarily involve the facility manager. However, to be effective it will

require coordination among the facility managers, risk managers, and financial managers. This is further discussed in Part B (for Facility Managers, Risk

Managers, and Financial Managers). In addition, it is the responsibility of the

healthcare organization’s top administrators to make sure that hazards are

assessed and risk reduction measures implemented.

Options for Seismic Risk Reduction

The most important consideration for earthquake safety in hospital buildings

is to reduce the risk of catastrophic structural collapse. Most likely in existing

vulnerable buildings, structural collapse poses the greatest threat to life in a

major earthquake. Choosing the method of protection from structural collapse in a deficient building requires two critical

decisions:

Replace or Rehabilitate: If you decide to

replace a building, new construction is

carried out according to modern codes

and can be assumed to meet current safety

standards. However, financial constraints,

historic preservation concerns, and other

community interests may make the replacement

option infeasible. In that case, rehabilitation should be

considered.

Single-Stage Rehabilitation2 or Incremental Rehabilitation: If

the rehabilitation option is chosen, there are still issues of cost and

disruption associated with the rehabilitation work. The cost of singlestage seismic rehabilitation has proved to be a serious impediment

to its implementation by many healthcare organizations.

Incremental seismic rehabilitation is specifically designed to address

and reduce the problems of cost and disruption.

Estimating the Costs and Benefits of Seismic Rehabilitation of

Existing Hospital Buildings

The direct and indirect costs of seismic rehabilitation of a building are:

 Engineering and design services

 Construction

 Disruption of building operations during construction

In Brief

Seismic rehabilitation of existing

vulnerable hospital

buildings can reduce future earthquake damage.

 Incremental seismic

rehabilitation is a

strategy to reduce

the cost of rehabilitation and related

disruption of

healthcare programs.

2 Single-stage rehabilitation refers to completing the rehabilitation in a single continuous

project.
Incremental Seismic Rehabilitation of Hospital Buildings

A-6

In Brief

 Whereas singlestage seismic rehabilitation of an

existing hospital

building represents

a significant cost,

rehabilitation actions can be divided

into increments and

integrated into

normal maintenance and capital

improvement

projects.

 The implementation

of incremental seismic rehabilitation

requires assessing

the buildings, establishing rehabilitation priorities,

and planning integration with other

projects.

The benefits of seismic rehabilitation of a building are:

 Reduced risk of death and injury of patients, doctors, nurses, and

staff

 Reduced building damage

 Reduced damage of hospital contents and equipment

 Reduced disruption of the delivery of healthcare services

Engineers have developed estimates of the reduction of earthquake damage

that can be achieved with seismic rehabilitation following the Federal Emergency Management Agency’s (FEMA’s) current rehabilitation standards. This

type of estimate, however, may significantly undervalue the benefit of seismic rehabilitation. In considering the return on seismic rehabilitation investments, it is appropriate to consider the value of damages avoided as well as

the difficult-to-quantify values of deaths, injuries, and disruption of hospital

functions avoided.

The primary obstacles to single-stage rehabilitation of vulnerable existing

hospital buildings are the cost of rehabilitation construction work and related

disruption of hospital functions. Incremental seismic rehabilitation offers

opportunities to better manage the costs and reduce disruption of rehabilitation. The following section introduces and explains incremental seismic rehabilitation in more detail.

A.4 Incremental Seismic Rehabilitation of Existing

Hospitals

Approach

Incremental rehabilitation phases seismic rehabilitation into an ordered series of discrete actions implemented over a period of several years, and

whenever feasible, these actions are timed to coincide with regularly scheduled repairs, maintenance, or capital improvements. Such an approach, if

carefully planned, engineered, and implemented, will ultimately achieve the

full damage reduction benefits of a more costly and disruptive single-stage

rehabilitation. Incremental seismic rehabilitation can be initiated in the nearterm as a component of planned maintenance and capital improvement with

only marginal added cost. Getting started as soon as possible on a program

of earthquake safety demonstrates recognition of responsibility for hospital

safety and can provide protection from liability.

Assessment of Deficiencies

A necessary activity that must precede a seismic rehabilitation program, be it

single-stage or incremental, is an assessment of the seismic vulnerability of

the healthcare organization’s building inventory. Facility managers can implement such an assessment using organization staff or outside engineering

consultants as appropriate. The assessment should rank the building inventory in terms of seismic vulnerability and identify specific deficiencies. FEMA

publishes a number of documents that can guide you through the assessment process. Portions of the assessment activities can be integrated with

other ongoing facility management activities such as periodic building inspections. Facility assessments and the FEMA publications available to help

you conduct them are discussed in more detail in Part B.
A-7

Part A

SCHEMATIC

INTEGRATION

OPPORTUNITIES

Exterior Wall Work

Interior Work

Roof Work

Rehabilitation Strategy

The incremental seismic rehabilitation program will correct the deficiencies

identified by the assessment. The order in which seismic rehabilitation increments are undertaken can be important to their ultimate effectiveness. There

are three aspects to prioritizing seismic rehabilitation increments:

Structural Priority: An initial prioritization of seismic rehabilitation

increments should be established primarily in terms of their

respective impact on the overall earthquake resistance of the

structure. Facility managers will begin with these priorities when

determining the order of seismic rehabilitation increments to be

undertaken. However, the final order of increments may deviate

from this priority order depending on other planning parameters.

Additional engineering analysis may be required for certain building

types when deviating from the structural priority order. This subject

is discussed in more detail in Part B, Section B.2, and Part C.

Use Priority: Healthcare organizations should consider planning

alternative future uses of their existing buildings. Some vulnerable

hospitals may be scheduled for demolition or changed to nonhospital uses (for example, storage or administration). Others may

be scheduled for expansion and intensification of use. These

considerations, among others, will influence the prioritization of

seismic rehabilitation increments.

Integration: A major advantage of the incremental

seismic rehabilitation approach is that specific

work items can be integrated with other building

maintenance or capital improvement projects

undertaken routinely. Such integration will reduce

the cost of the seismic rehabilitation action by

sharing engineering costs, design costs, and

some aspects of construction costs. Integration

opportunities are a key consideration in adapting

the sequence of actions suggested by the

foregoing discussions of rehabilitation priorities.

Integration opportunities are discussed in more

detail in Part C, Section C.2.

Incremental Seismic Rehabilitation Plan

An essential feature of implementing incremental seismic

rehabilitation in specific hospital buildings is the development and documentation of a seismic rehabilitation plan.

The seismic rehabilitation plan will include all the anticipated rehabilitation increments and their prioritization as

previously discussed. The documentation will guide the

implementation of the incremental seismic rehabilitation

program and should ensure that the healthcare organization does not lose sight of overall rehabilitation goals during implementation of individual increments.

Recommended Actions

1. Communicate the importance of assessing your

organization’s risks and pass this manual on to

the staff members responsible for facility

management, risk management, and financial

planning. Specify that they develop an analysis of
Incremental Seismic Rehabilitation of Hospital Buildings

A-8

the current seismic risk of your buildings and a strategy for risk

reduction.

2. Promptly initiate a program of earthquake risk reduction in your

organization’s buildings located in an earthquake-prone zone that

were not designed and constructed to meet modern building codes.

3. Consider incremental seismic rehabilitation as a cost-effective

means to protect the buildings and, most importantly, the safety of

patients, doctors, nurses, and staff, because it is a technically and

financially manageable strategy that minimizes disruption of

hospital activities.
B-1

Part B

B

Planning and Managing

the Process for Earthquake

Risk Reduction in Existing

Hospital Buildings

For Facility Managers,

Risk Managers, &

Financial Managers

Introduction

Part B of this manual is written specifically for

healthcare organization and hospital facility managers, risk managers, and financial managers concerned

with the seismic safety of their buildings. The

organization’s senior management may have requested

you, the manager, to make a recommendation to address seismic safety in hospitals or may have made

the decision to address it, or there may already be a

seismic safety program in place. Part B describes when

and how specific activities that will accomplish the goal

of seismic risk reduction can be introduced into an ongoing hospital facility management process. Part B also

provides the framework and outline that can be used

by the facility managers, risk managers, and financial

managers in developing and communicating their recommendations to senior management.

An incremental seismic rehabilitation program is one of several seismic risk

reduction strategies that can be implemented in hospital buildings. It can be

implemented separately or in combination with other seismic risk reduction

actions. If you determine that such a program is appropriate for your organization, the planning and implementation of incremental seismic rehabilitaPart

In Brief

 Planning for earthquake risk reduction in hospitals

requires a coordinated and integrated effort by

facility managers,

risk managers, and

financial managers.

 Ten specific activities can be added

to the current facility management

process to implement an incremental seismic

rehabilitation program.

 Nine additional

activities can be

added to the facility

management process to further reduce seismic risk.

 There are three

ways to start reducing seismic risk.
Incremental Seismic Rehabilitation of Hospital Buildings

B-2

tion should be integrated into the facility management processes and integrated with other seismic risk reduction actions that will complement it or

support it.

B.1 Integrating the Efforts of Facility Management,

Risk Management, and Financial Management

Preparing an analysis of a healthcare organization’s earthquake risk reduction needs, and planning and managing such a process, benefits from an

integrated effort by the organization’s facility managers, risk managers, and

financial managers, or by the administrators charged with those respective

responsibilities. Such an integrated effort may be a departure from current

practices, but such collaboration is the key to improving safety cost-effectively and with a minimum of disruption.

Facility managers currently carry out their planning activities by considering

the parameters of healthcare delivery programs, medical technology, area

demographics, and the physical condition and projected useful life of the

existing healthcare facilities. Often they consider pressing social issues such

as physical security and equity. Some of these issues become federal or

local government mandates, such as asbestos and lead abatement or energy conservation. Sometimes facility managers consider the risks to hospital buildings from natural disasters such as earthquakes or windstorms.

Risk managers, relatively recent additions to many healthcare organizations,

carry out their planning activities by considering three aspects: risk identification, risk reduction, and risk transfer. The latter generally involves the purchase of insurance or the contribution to a risk pool. Currently, risks in

healthcare organizations are classified into three broad areas: medical risk,

employee risk, and facility and environmental risk. While risk managers are

keenly aware of the extreme healthcare demands that natural disasters may

place on their hospital facilities, rarely do they consider the risks to the facilities and their occupants themselves from these disasters. Rather, they

tend to assume that risks from natural disasters are addressed by building

codes and similar regulations.

Financial managers currently deal with facilities by controlling and managing maintenance budgets, capital improvement budgets, and insurance budgets. The facility managers and risk managers present the demands on

these budgets to the financial managers, but rarely are the potential

tradeoffs among these budgets considered. The costs and benefits of various options of facility risk management are rarely explicitly addressed.

Addressing the problem of earthquake risk reduction requires establishing

active communication among the three management functions and coordinating activities into an integrated planning and management effort. Facility

and risk managers will have to consider facility risk, and financial managers

will have to consider the costs and benefits of various options for managing

facility risk. Specific recommendations on implementing such an effort are

provided in the following sections.
B-3

Part B

B.2 Integrating Incremental Seismic Rehabilitation

into the Facility Management Process

B.2.1 A Model of the Facility Management Process for Existing

Hospital Buildings

The typical facility management process for existing hospital buildings consists of seven phases of activities: Acquisition, Current Building Use, Accreditation, Planning, Maintenance & Rehabilitation Budgeting, Maintenance

& Rehabilitation Funding, and Maintenance & Rehabilitation Implementation. Each phase consists of a distinct set of activities as follows:

Acquisition: due diligence

Current Use: facility occupancy, facility operation, facility maintenance, and facility assessment

Accreditation: Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or alternate accreditation emergency management planning

Planning: strategic planning and facility planning

Budgeting: capital budgeting, maintenance budgeting, and insurance

budgeting

Funding: financing of capital, maintenance, and insurance budgets

Implementation: capital improvement and maintenance

This process is sequential, progressing from acquisition through implementation of rehabilitation in any given building. A healthcare organization that

has a large inventory of buildings is likely to have ongoing activities in all of

these phases in different buildings. The process is illustrated in the following

diagram. The Appendix to this manual, Additional Information on Hospital

Facility Management, contains a discussion of the specific phases and the

activities therein for hospital administrators seeking further detail on the

facility management process. This is a generalized model subject to local

variation.

B.2.2 Elements of an Incremental Seismic Rehabilitation

Program

The following activities are considered essential elements of an incremental

seismic rehabilitation program for hospitals:

1. Due Diligence Analysis

2. Seismic Screening

3. Seismic Evaluation

4. Emergency Management Planning for Accreditation

5. Developing a Risk Reduction Policy

6. Seismic Rehabilitation Planning for Specific Buildings

7. Staging Seismic Rehabilitation Increments
Incremental Seismic Rehabilitation of Hospital Buildings

B-4

8. Budget Packaging

9. Bond Packaging

10. Seismic Rehabilitation Project Management

B.2.2.1 Due Diligence Analysis

In regions of high and moderate seismicity, due diligence should include a

probabilistic analysis of potential earthquake risks. Such an analysis considers damage from earthquakes of all levels of intensity, and will provide information on seismic vulnerabilities in the building. If the building is

acquired, the due diligence analysis will provide information for the initiation of a full seismic assessment. Probabilistic analysis, because of its detail

and scope, will be more expensive than more simplistic Probable Maximum

Loss (PML) analysis.

B.2.2.2 Seismic Screening

Following building acquisition, seismic screening of the healthcare

organization’s building inventory is the first step of the incremental seismic

rehabilitation process. Seismic screening procedures can be incorporated

into other facility assessment activities. Begin with a determination of the

status of the archival records. If building plans are available, a document

review for the determination of building structure types is the first step in

seismic screening. The following chart can be used to obtain an overall view

of seismic concerns based on the seismic hazard map in Part A.

The Federal Emergency Management Agency (FEMA) has developed FEMA

154, Rapid Visual Screening of Buildings for Potential Seismic Hazards: A

Handbook, Second Edition1 as guidance for seismic screening of an inventory of buildings. It describes a technique for identifying the relatively more

vulnerable buildings in a large inventory so that they can be addressed in

more detail.

The FEMA 154 publication is nationally applicable and addresses all building

types. In some cases, the screening will suggest specific seismic rehabilitation opportunities that do not require additional engineering and risk analyses.

Incremental Seismic

Rehabilitation

Element 2

Seismic Screening

Incremental Seismic

Rehabilitation

Element 1

Due Diligence

Analysis

1 To order this and other FEMA publications, you may write to FEMA, PO Box 2012,

Jessup, MD 20794-2012; or you may call 1-800-480-2520, Monday - Friday, 8:00 a.m. -

5:00 p.m., eastern time; or you may fax your request to 301-362-5335.

Initial Hospital

Facility Manager/

Risk Manager

Screening of

Seismic Concerns

L n evel of Seismic Concern

b e y Typical Building Type

L * evel of Seismic Concern by Building Location*

G n ree Y w ello R d e

Wood Frame L w o H h ig

Steel Frame L w o H h ig

Concrete Frame V w ery Low M m ediu V h ery High

Unreinforced Masonry L w o H h ig V h ery High

Patterned after recommendations developed by Dr. Charles Scawthorn for the California Seismic Safety

Commission's Earthquake Risk Management: A Toolkit for Decision Makers.

* Locations refer to the seismic hazard map in Part A, Section A.1.
B-5

Part B

The incorporation of seismic screening into ongoing facility assessment

activities requires assigning the screening to the appropriate inspectors. If

inspections are periodically carried out in the healthcare organization’s

buildings for other purposes such as life safety, insurance, occupational

health and safety, or hazardous materials identification, it may be possible

to assign the seismic screening to the same inspectors with some additional

training. Alternatively, the seismic screening can be assigned to a consulting

architect or engineer.

B.2.2.3 Seismic Evaluation

Seismic evaluation is an engineering analysis of individual healthcare buildings. It usually follows the seismic screening, when the buildings identified

as relatively more vulnerable are subjected to a more detailed analysis.

However, in some cases, such as when the organization’s building inventory

is small, seismic evaluation of individual buildings may be the first step of

the incremental seismic rehabilitation process.

Guidance for seismic evaluation of buildings is contained in standard ASCE

31, Seismic Evaluation of Existing Buildings,

2

 which is based on FEMA 310,

Handbook for the Seismic Evaluation of Existing Buildings—A Prestandard.

The standard provides engineering guidance on how to evaluate categories

of buildings in order to identify deficiencies and determine effective rehabilitation measures.

Seismic evaluation can be done by the healthcare organization’s professional staff or by a consulting engineer.

B.2.2.4 Emergency Management Planning for Accreditation

During the Accreditation Phase, seismic screening (B.2.2.2) and seismic

evaluation (B.2.2.3) can support and enhance the demonstration of compliance with JCAHO’s Environment of Care (EC) standards EC.1.4 and EC.2.4

(amended and expanded in January 2001). The EC standards require hospital, ambulatory care, behavioral health, home care, and long term care organizations to develop and implement a management plan that ensures

effective response to emergencies affecting the delivery of healthcare.

The American Society for Healthcare Engineering (ASHE) has developed a

tool, entitled Hazard Vulnerability Analysis,3 to help healthcare organizations

develop an emergency management plan. It is a simple matrix that lists a

variety of hazards, including earthquake, and requires the rating of each in

terms of its probability (on a 4-point scale from “none” to “high”), risk (on a

5-point scale from “low disruption” to “life threat”), and preparedness (on a

3-point scale from “poor” to “good”). The values on each scale are multiplied to arrive at a total value for each hazard. The tool instructs: “Determine

a value below which no action is necessary. Acceptance of risk is at the discretion of the organization.”

Seismic screening and seismic evaluation can add more sophisticated earthquake vulnerability analysis to the emergency management plan required

for JCAHO accreditation.

Incremental Seismic

Rehabilitation

Element 3

Seismic Evaluation

Incremental Seismic

Rehabilitation

Element 4

Emergency

Management

Planning for

Accreditation

2 ASCE 31 can be obtained from the American Society of Civil Engineers at 1-800-548-

2723.

3 Healthcare Facilities Management Series, Management Monograph #055920, Susan B.

McLaughlin, February 2001, ASHE of the American Hospital Association.
Incremental Seismic Rehabilitation of Hospital Buildings

B-6

B.2.2.5 Developing a Risk Reduction Policy

Convince the board of directors to adopt a clear policy statement supporting

seismic risk reduction. Such a policy should, at a minimum, establish seismic performance objectives for the healthcare organization’s buildings. Seismic performance objectives define the target performance of a building

following an earthquake of a specified intensity. The policy and objectives

should be developed and documented as part of the seismic rehabilitation

planning process.

B.2.2.6 Seismic Rehabilitation Planning for Specific Buildings

FEMA has developed engineering guidance to plan seismic rehabilitation for

specific buildings, including FEMA 356, Prestandard and Commentary for

the Seismic Rehabilitation of Buildings, which includes specific techniques

for analyzing and designing effective seismic rehabilitation. The planning

task entails four specific facility planning subtasks:

1. Establish seismic target performance levels. With cooperation

between hospital staff and central administration, establish the

performance level desired in each of the healthcare organization’s

buildings following an earthquake. Performance levels used in

FEMA 356 are, in declining level of protection:

 Operational

 Immediate Occupancy

 Life Safety

 Collapse Prevention

This is an expansion of the two performance levels, Immediate

Occupancy and Life Safety, included in ASCE 31, Seismic Evaluation of Existing Buildings.

Incremental Seismic

Rehabilitation

Element 6

Seismic

Rehabilitation

Planning for

Specific Buildings

Emergency management plans are required to address the four phases of

emergency management activities:

• Mitigation

• Preparedness

• Response

• Recovery

The official JCAHO newsletter, Perspectives, dated December 2001, includes the following definition of an emergency:

“It is a natural or manmade event that suddenly or significantly

• disrupts the environment of care (for example, damage to the organization’s buildings, and grounds due to severe windstorms, tornadoes, hurricanes, or earthquakes);

• disrupts care and treatment (for example, loss of utilities—power, water, telephones—due to floods, civil disturbances, accidents, or emergencies within the

organization or in its community); or

• changes or increases demands for the organization’s services (for example,

bioterrorist attack, building collapse, or airplane crash in the organization’s community).”

The newsletter continues with the following discussion of mitigation, which is one part

of the emergency management plan:

“Mitigation activities lessen the severity and impact of a potential emergency. Mitigation begins by identifying potential emergencies (hazards) that may affect the

organization’s operations or the demand for its services, followed by implementing a

strategy that supports the perceived areas of vulnerability within the organization.”

Incremental Seismic

Rehabilitation

Element 5

Developing a Risk

Reduction Policy
B-7

Part B

The figures adapted from FEMA 356

on this and the following page demonstrate the use of these performance

levels. Reasonable objectives and expectations should be considered for

moderate, severe, and rare great

earthquakes.

2. Prioritize rehabilitation opportunities: Carry out additional engineering

and risk analysis in order to prioritize

the seismic rehabilitation opportunities identified in the seismic evaluation in terms of risk reduction. ASCE

31 and FEMA 356 include lists of seismic rehabilitation measures as a function of common building types.

Priorities for these measures are established in terms of respective contribution to the overall earthquake

resistance of the structure.

Apply a “worst first” approach. Attend

to heavily used sections of the most

vulnerable buildings housing the

greatest number of occupants, as well

as to areas housing critical functions

and equipment. For example, higher

priorities may be given to rehabilitation of hospital areas where patients

and staff spend most of their time, and

to corridors, stairs and exits, which

will facilitate the evacuation of the

building in an earthquake.

3. Define increments: Break down the

specific seismic rehabilitation opportuTarget Building

Performance

Levels and Ranges

nities into discrete incremental rehabilitation measures that make

sense in engineering and construction terms. When establishing

increments, consider scheduling to minimize the disruption to normal hospital operations.

4. Integrate with other rehabilitation work: Link each incremental rehabilitation measure with other related facility maintenance or

capital improvement work. The related work classifications may

differ from one healthcare organization to another, but will fall into

the following generic categories:

 Building envelope improvements

 Interior space reconfiguration

 Life safety and accessibility improvements

 Refinishing and hazardous materials removal

 Building systems additions, replacements, and repairs

 Additions to existing buildings

 Medical technology improvements

 Patient care improvements
Incremental Seismic Rehabilitation of Hospital Buildings

B-8

Opportunities for project integration are listed in Part C, Section 2

of this manual. Some examples of the opportunities you can use to

link projects are: when accessing concealed areas, when removing

finishes and exposing structural elements, when performing work

in a common location, when sharing scaffolding and construction

equipment, and when sharing contractors and work force.

The four subtasks described above form an iterative process. The definition

and related cost estimation of increments, as well as the integration with

other maintenance and capital improvement projects (subtasks 3 and 4),

may lead to a revision of target performance levels (subtask 1) or to specific

analysis carried out as part of subtask 2.

Damage Control and Building Performance Levels
B-9

Part B

B.2.2.7 Staging Seismic Rehabilitation Increments

Determine the number and scope of incremental stages that will be undertaken and the length of time over which the entire rehabilitation strategy will

be implemented.

Estimates of seismic damage can be quantified in terms of percentage of

building value damaged. Annual seismic damage is calculated as the probable damage that can result in any year from all possible earthquakes. The

benefits of seismic rehabilitation are quantified as the reduction in annual

seismic damage resulting from specific rehabilitation actions (also quantified in terms of percentage of building value). A generalized life-cycle benefit analysis shows that incremental approaches can return a substantial

portion of the expected benefits of single-stage seismic rehabilitation carried out now.

The schematic diagram above illustrates such a life-cycle benefit analysis.

The three wide arrows represent the benefits of single-stage rehabilitation

occurring at three points in time: now, in 20 years, and in 40 years. Clearly,

the largest benefit derives from a single-stage rehabilitation done now, and

it is designated as 100%. The benefits of single-stage rehabilitation done in

the future must be discounted and expressed as some percentage lower

than 100%, as represented by the decreased arrows. The stepped portion of

the diagram represents incremental rehabilitation starting soon and completed in four increments over 20 years. The benefits of the future increIncremental Seismic

Rehabilitation

Element 7

Staging Seismic

Rehabilitation

Increments
Incremental Seismic Rehabilitation of Hospital Buildings

B-10

ments must also be discounted, and the benefit of the completed incremental rehabilitation is therefore expressed as a percentage lower than 100%,

but higher than the single-stage rehabilitation in year 20. Reducing the overall duration of the incremental rehabilitation will increase its benefit, and

extending the duration will decrease it.

Incremental seismic rehabilitation affords great flexibility in the sequence

and timing of actions when the following precautions are kept in mind:

 It is important to get started as soon as possible. Any early reduction of risk will provide benefit over the remaining life of the building. Delaying action extends risk exposure. The incremental

approach can be more effective than a delayed, single-stage rehabilitation, as long as one gets started soon.

 Even if the completion of the incremental program takes 10 or 20

years, most of the risk reduction benefit is realized.

 There is a wide margin of error. For example, you may unintentionally increase the probability of damage in the first few years due to

an initial rehabilitation increment that inadvertently makes the

building more vulnerable to damage, and still realize the benefit of

risk reduction if you complete the incremental rehabilitation over a

reasonable period.

B.2.2.8 Budget Packaging

The hospital directors and facility managers should carefully plan how to

present the incremental seismic rehabilitation budgets, given the political

and financial realities of the healthcare organization, and Medicare’s depreciation schedules.

The facility capital improvements and maintenance budget proposals, generated both locally at the facility and centrally at organization headquarters,

are results of the facility planning process. The budget, however, is also a

vehicle for establishing funding priorities, through a board decision, a bond

issue, or other process. It is unlikely for healthcare organizations in most

parts of the United States to be able to raise funds for a comprehensive

seismic rehabilitation program of all their hospitals. While the incremental

rehabilitation approach appears to be a viable alternative, in some organizations it may be necessary to “package” incremental seismic rehabilitation

with other work in order to get it funded.

In regions of moderate seismicity and low seismic awareness (parts of New

York and New England, for example), it may be useful to concentrate on

rehabilitation measures that also reduce the risk of loss due to other natural

or man-made forces, such as high winds or terrorist attack. Such a multihazard approach will help justify mitigation investments.

For those parts of the country where the understanding of earthquake risk is

limited, it may be necessary and appropriate to combine seismic rehabilitation costs with normal maintenance budgets.

B.2.2.9 Bond Packaging

Since a bond issue is one of the three financing mechanisms for seismic

rehabilitation (in addition to revenue and interest income), one must ensure

that bond-financed incremental seismic rehabilitation does not include categories of work precluded by law or regulation.

Incremental Seismic

Rehabilitation

Element 8

Budget Packaging

Incremental Seismic

Rehabilitation

Element 9

Bond Packaging
B-11

Part B

Experience with bond-financed incremental seismic rehabilitation has been

limited to school districts, and the most extensive is that of the Seattle Public Schools

program. Seattle’s experience may be of interest to some office building owners. Seattle

Public Schools used two types of bonds to fund its program. Capital Levy Bonds were used

to fund projects with smaller seismic rehabilitation increments categorized as repair and

major maintenance. Capital Improvement Bonds were used to fund major projects categorized as modernization of hazardous buildings. This distinction was necessary because of

Washington state law. Similar distinctions may be required in other parts of the country.

Incremental Seismic

Rehabilitation

Element 10

Seismic

Rehabilitation

Project

Management

B.2.2.10 Seismic Rehabilitation Project Management

The implementation of the selected incremental seismic rehabilitation measures in combination with other building work may require added attention

to project design and bid packaging.

 Fully brief or train in-house architects/engineers or outside consultants preparing the bid documents on the rationale behind the rehabilitation measures, in order to assure that the seismic risk

reduction objectives are achieved.

 Ensure the continuity of building documentation from the analysis

and design stages through construction and as-built drawings.

 Conduct a pre-bid conference to fully explain to all prospective bidders the seismic risk reduction objectives and the rationale for their

selection.

Federal and state mandates and programs represent opportunities for seismic rehabilitation. Externally, federal and state programs may establish requirements affecting the implementation phase that have implications for

healthcare facilities (e.g., Americans with Disabilities Act [ADA] and Occupational Safety and Health Administration [OSHA] requirements). Additionally,

governmental funding programs may mandate facility requirements, such

as energy conservation, in participating healthcare organizations. However,

there are currently no seismic rehabilitation mandates or implications in any

federal or state programs related to non-federal hospitals outside of California.

B.2.3 Integration into the Hospitals Facility Management

Process

The following diagram illustrates the integration of the 10 elements discussed in the preceding sections (B.2.2.1 through B.2.2.10) into the

healthcare facility management process. The elements are shown in the

phase of the management process in which they are most likely to be implemented.
Incremental Seismic Rehabilitation of Hospital Buildings

B-12

B.3 Opportunities for Seismic Risk Reduction in

Support of Integrating Incremental Seismic

Rehabilitation into the Facility Management

Process

The following nine opportunities for seismic risk reduction will support the

integration of an incremental seismic rehabilitation program:

1. Responding to Occupant Concerns

2. Emergency Management/Response Planning

3. Emergency Management/Mitigation Planning

4. Developing a Risk Reduction Policy

5. Incorporating Federal and State Mandates and Programs

6. Coordinating with Risk and Insurance Managers

7. Becoming Familiar with Applicable Codes

8. Establishing and Maintaining a Roster of Design Professionals

9. Negotiating Code Enforcement

These opportunities are created by internal and external factors that typically influence the healthcare facility management process. Internal factors

are generated within the healthcare organization and its administration.

External factors are imposed on organizations by outside pressures, such as

the government, insurance regulations and practices, or the financial climate. The following factors may influence each respective phase:

Acquisition: internally generated purchase forms that guide purchase decisions

Current Use: external state licensure, health insurance, property

and liability insurance, federal and state programs, and emergency

management and internal occupant concerns

Accreditation: external accreditation procedures

Planning: internal board policies, and external government mandates and health insurance requirements

Budgeting: internal budgetary constraints and risk management

Funding: external economic conditions, federal and state programs, and bond financing regulations

Implementation: external federal and state mandates and programs, codes and code enforcement

The Appendix to this manual, Additional Information on Hospital Facility

Management, contains a discussion of the specific phases and the related

internal and external influences for those seeking more information on the

facility management process.

The following diagram illustrates the integration of these opportunities into

the hospital facility management process. The opportunities are shown in

the phase of the management process in which they are most likely to be

implemented. Each opportunity is discussed in detail in the following sections (B.3.1 through B.3.9).
B-13

Part B

B.3.1 Responding to Occupant Concerns

Track all staff and patient concerns that relate to earthquake vulnerability,

and make sure they are understood and considered in the planning phase.

Be alert to occupant concerns, especially the safety concerns of the staff.

They can be a source of considerable influence on risk managers as well as

a potentially significant pressure on the facility management process. Occupant concerns may become the vehicle for channeling internal pressures of

all kinds, including policies adopted by the Board, into capital improvements

and maintenance actions.

B.3.2 Emergency Management/Response Planning

Establish a liaison with emergency management agencies and volunteer

agencies, such as the Red Cross.

State or local emergency management agencies usually assign specific

roles that specific hospital buildings must perform in case of natural and

manmade disasters, including earthquakes. This may affect the occupancy

activities by requiring periodic exercises involving building occupants.

Emergency management plans related to the role of hospital facilities in a

disaster may be general and broad, or detailed and specific.

Become familiar with the role of regional hospital buildings in the local

emergency response plans, and if it is a significant role, become active in

the emergency planning process. Define the role in specific detail, assigning

exact functions to particular facilities. The role of specific hospital buildings

in the local emergency response plans should affect seismic performance

objectives and the priority of specific seismic rehabilitation measures. Therefore, there should be full coordination between a healthcare organization’s

emergency planning and facility planning functions.
Incremental Seismic Rehabilitation of Hospital Buildings

B-14

B.3.3 Emergency Management/Mitigation Planning

Establish a liaison with emergency management mitigation planners at the

state and local levels.

Endeavor to incorporate the hospital building earthquake mitigation into the

state’s mitigation plan, and to recognize the healthcare organization’s incremental seismic rehabilitation measures as elements of the mitigation plan.

Federal resources and funds are available to states for the support of disaster mitigation planning activities. Federal matching funds may be available

for the implementation of mitigation following a presidentially declared disaster. These resources are available through the Robert T. Stafford Disaster

Relief and Emergency Assistance Act (P.L. 100-707). Healthcare organizations

should make every effort to obtain these resources.

B.3.4 Developing a Risk Reduction Policy

Convince the board of directors to adopt a clear policy statement supporting

seismic risk reduction. Such a policy should, at a minimum, establish seismic performance objectives for the healthcare organization’s buildings. Seismic performance objectives define the target performance of a building

following an earthquake of a specified intensity. The policy and objectives

should be developed and documented as part of the seismic rehabilitation

planning process.

B.3.5 Incorporating Federal and State Mandates and

Programs

Become familiar with the seismic rehabilitation requirements imposed on

the healthcare organization’s hospitals by federal and state programs, currently or under discussion for the future, and take them into account in planning activities.

B.3.6 Coordinating with Risk and Insurance Managers

Establish coordination between the facility management and risk management functions in the healthcare organization.

The healthcare organization’s risk and insurance management may have a

direct or indirect role in the budgeting phase of the facility management

process with regard to decisions related to insurance as well as other budget categories.

In areas of seismic risk, the risk of building loss or damage, the risk of occupant death or injury, and the risk of healthcare organization liability must all

be assessed. The decision of whether to seek earthquake property and casualty insurance coverage and general liability coverage must be made. Insurance companies that offer such coverage do not usually offer incentives to

customers to undertake loss reduction measures in the form of seismic rehabilitation. However, this situation might change, and the question may be

subject to negotiation with some companies. Insurance carriers are more

than willing, when asked, to provide building owners with Loss Control and

Prevention Reports that include recommendations for loss prevention.

The organization’s risk manager should be fully informed on individual hospitals’ approaches to seismic risk reduction, and should be a participant in

the planning process. This may entail the establishment of new communication lines between central organization staff and local hospital staff.

Currently there

are no seismic

rehabilitation

mandates or implications in any federal

or state programs

related to existing

hospitals outside of

California. In California, healthcare systems are subject to

Senate Bill 1953

(SB1953) that has

established three

interim milestone

dates (January 1,

2002; January 1,

2008; and January 1,

2030) for progressively bringing all

hospital buildings

into full seismic compliance with California Building Codes by

January 1, 2030.
B-15

Part B

If seismic risk is covered by the organization’s insurance carrier or by an

insurance pool, it may be possible to negotiate a rate reduction, deductible

reduction, or increased maximum benefit. On the other hand, the insurer

may require some seismic rehabilitation as a condition of coverage. Additionally, a regional or statewide risk and insurance pool in which an organization may participate could become an active participant in its facilities

assessment and planning processes.

B.3.7 Becoming Familiar with Applicable Codes

Become familiar with the seismic rehabilitation requirements imposed in

your building inventory’s jurisdictions by building codes or other codes and

ordinances, currently or under discussion for the future such as rehabilitation codes, and take them into account in planning activities.

B.3.8 Establishing and Maintaining a Roster of Design

Professionals

Develop and maintain a roster of architects, engineers, and other consultants with expertise in the fields of seismic assessment of buildings, seismic

design, and risk analysis to quickly make use of their specialized expertise

when needed. Such qualified professionals can be identified with the assistance of professional societies such as the American Society of Civil Engineers, the American Institute of Architects, or the Earthquake Engineering

Research Institute.

B.3.9 Negotiating Code Enforcement

Discuss the organization’s planned incremental seismic rehabilitation actions with the applicable code enforcement authorities.

Building codes impose requirements on the implementation phase in cases

of repair, alteration, or addition to existing buildings. These requirements

may be enforced by a state or local agency. Such requirements can add

costs to a project and jeopardize feasibility if not taken into account.

Although additions must comply with building code seismic requirements,

few codes mandate seismic rehabilitation in repair and alteration projects.

Incremental seismic rehabilitation is consistent with most building code

requirements applicable to existing buildings.

If applicable, negotiate with code enforcement authorities an optimization of

life safety and risk reduction when undertaking seismic rehabilitation. Some

code enforcement agencies negotiate required life safety and other improvements with owners of existing buildings who undertake voluntary

building rehabilitation. Such negotiations attempt to strike a compromise

between safety, feasibility, and affordability.
Incremental Seismic Rehabilitation of Hospital Buildings

B-16

B.4 Preparing a Plan for the CEO and the Board

This section provides guidance to healthcare facility managers, risk managers, and financial managers when preparing a proposal for a seismic safety

program in response to top management’s request.

B.4.1 Getting Started

The facility, risk, and financial managers of the healthcare organization

should prepare a proposal for a seismic risk reduction program. This proposal should be based on an analysis of each of the elements of an incremental seismic rehabilitation program (B.2.2) and opportunities for seismic

risk reduction (B.3) as discussed above, and additional components (B.5)

discussed below. The proposal should include the following elements:

 A discussion of each recommendation in Part B from the perspective of the organization’s current facility management, risk management, and financial management practices. This may take the form

of a comprehensive rewriting of Part B.

 A specific plan and recommendation for initiating the first two

steps following building acquisition, Seismic Screening and Seismic Evaluation. The plan should include a budget and schedule of

activities.

 A request for the budget for these first steps.

B.4.2 Getting Started Plus

If the necessary resources are available to the facility manager, perform a

rapid visual screening, as outlined in B.2.2.2, prior to preparing the program

proposal. Then, expand the proposal based on the known inventory of potentially vulnerable buildings as determined in the screening process.

B.4.3 Getting Started with a Jump Start

If the organization has a current 5-year capital improvement plan or its

equivalent, add the following details to the proposal discussed above:

 Identify existing buildings currently included for rehabilitation in

the current 5-year plan.

 Perform a preliminary review of their seismic vulnerabilities, as

outlined in B.2.2.2.

 Using Part C of this manual, identify potential seismic rehabilitation

increments that could be integrated with the rehabilitation program.

 Add a FEMA 356, Prestandard and Commentary for the Seismic

Rehabilitation of Buildings, seismic rehabilitation design task to the

rehabilitation projects.
B-17

Part B

B.5 Additional Components of a Comprehensive

Earthquake Safety Program

In addition to integrating an incremental seismic rehabilitation program into

the hospital facility management process and integrating opportunities to

support and implement such a program, there are additional activities that

can become part of a comprehensive earthquake safety program for hospitals. These activities can be implemented at any time.

B.5.1 Building Contents Mitigation

Initiate housekeeping or maintenance measures to reduce or eliminate risks

from earthquake damage to equipment, furnishings, and unsecured objects

in buildings. Work may include such tasks as:

 Fastening laboratory equipment

 Anchoring file cabinets, storage shelves, and other large furnishings

 Restraining objects on shelves

 Securing the storage of hazardous materials such as chemicals

FEMA has developed materials that contain information on contents mitigation. These include FEMA 74, Reducing the Risk of Nonstructural Earthquake

Damage: A Practical Guide, and FEMA 241, Identification and Reduction of

Nonstructural Earthquake Hazards in Schools. (While the latter is addressed

primarily to schools, it is equally applicable to other facility types.)

B.5.2 Earthquake Drills

Introduce earthquake drills and appropriate earthquake preparedness materials into the regular hospital emergency preparedness program. These drills

should address the influx of patients and casualties as well as hospital building failure. Knowing what to do and where to go in an emergency can be

critical to life safety in earthquakes.

C-1

Part C

C

Tools for Implementing

Incremental Seismic

Rehabilitation in Existing

Hospital Buildings

For Facility Managers

Introduction

A healthcare organization or hospital facility manager

charged with the responsibility of implementing a program of incremental seismic rehabilitation may be entering unfamiliar territory. Part C of this manual is

intended to provide the facility manager with information and tools regarding building systems maintenance,

repair, and rehabilitation that should be of assistance

in implementing such a program.

A program of incremental seismic rehabilitation is likely to be more affordable and less disruptive if specific increments of seismic rehabilitation are

integrated with other maintenance and capital improvement projects that

would be undertaken regardless of whether or not seismic issues were being

addressed.

Guide to Sections C.1 and C.2

Section C.1, How to Use Engineering Services, provides the facility manager

with practical information on the special services offered by seismic rehabilitation professionals. Several essential activities must be carried out by the

facility manager in order to successfully implement a program of incremental

seismic rehabilitation. (These activities are identified and discussed in Part B

of this manual.) Some of these activities may require professional architecPart
Incremental Seismic Rehabilitation of Hospital Buildings

C-2

tural and engineering services that differ from or exceed the traditional services usually retained by healthcare organizations.

Section C.2, Discovering Integration Opportunities for Incremental Seismic

Rehabilitation, provides the facility manager with a set of tools to link specific

increments of seismic rehabilitation with specific maintenance and capital

improvement projects. These tools will assist the facility manager in defining

appropriate scopes of work for projects that will include incremental seismic

rehabilitation actions.

A companion document, Engineering Guideline for Incremental Seismic Rehabilitation, FEMA 420, provides design professionals with additional technical guidance for the detailed design of specific rehabilitation projects.

C.1 How to Use Engineering Services

To successfully implement integrated incremental seismic rehabilitation, a

healthcare organization or hospital facility manager should retain engineering services for three specific phases:

 Seismic screening and evaluation

 Incremental seismic rehabilitation planning and design

 Construction period support

Seismic Screening and Evaluation

Seismic screening and evaluation of the healthcare organization’s building

inventory begins with a review of archival drawings and specifications, if

available, to determine the types of construction used. This determination is

essential for all subsequent phases. If drawings and specifications are not

available, this determination must be made on the basis of visual inspection.

Following this review, building inventories should be screened in a process

based on FEMA 154, Rapid Visual Screening of Buildings for Potential Seismic Hazards: A Handbook, Second Edition. The goal of the screening is to

identify vulnerabilities in the inventory. Buildings that have little or no vulnerability are separated out.

For the buildings identified as vulnerable, the next category of service is a

detailed seismic evaluation using ASCE 31, Seismic Evaluation of Existing

Buildings, which is based on FEMA 310, Handbook for the Seismic Evaluation

of Existing Buildings: A Prestandard. Smaller healthcare organizations with

few buildings may begin with this evaluation, which addresses individual

buildings and identifies both structural and nonstructural deficiencies that

require rehabilitation. The output of each building evaluation is a list, possibly prioritized, of needed specific rehabilitation actions.

A hospital or healthcare organization may retain the services of a single engineering firm to perform both the screening and evaluation, or it can retain a

firm for screening and one or more firms for building evaluation.

Incremental Seismic Rehabilitation Planning and Design

A complete seismic rehabilitation plan covering all the deficiencies identified

in the evaluation should be prepared for each building that has been evaluated. This can be done using ASCE 31 and FEMA 356, Seismic Rehabilitation

of Buildings. However, in incremental seismic rehabilitation the correction of

all the deficiencies is not implemented at once, but rather in discrete increments over a period of time. In order to accomplish this, it is necessary to

carry out four specific steps:

In Brief

 Engineering services should be

retained for three

specific phases:

seismic screening

and evaluation,

incremental seismic

rehabilitation planning and design,

and construction

period support.

 Continuity of building documentation

is of special importance.
C-3

Part C

 Establish target seismic performance levels

 Prioritize seismic rehabilitation opportunities

 Define increments

 Integrate seismic rehabilitation into maintenance and capital

improvement programs

Each of these steps is amplified in the discussion of the hospital facility planning phase in Section B.2.

The potential for unintentional weakening of the building as the result of a

particular increment should be analyzed carefully and must be avoided. This

subject is discussed in more detail in the companion document, Engineering

Guideline for Incremental Seismic Rehabilitation, FEMA 420.

Seismic rehabilitation planning and design may be carried out by the same

engineering firm that performed the evaluation, or by a separate firm. Close

coordination with the healthcare organization’s risk management functions is

a prerequisite for the successful implementation of performance objectives

and prioritization steps. The definition of increments and integration of activities will also require close coordination with financial managers so as to be

consistent with budgeting and funding processes, as discussed in Part B. The

contractual agreement covering this work should reflect the fact that some of

the work is implemented immediately and some of the work is left to the

future.

Construction Period Support

Construction period support for incremental seismic rehabilitation is much

the same as for any other construction project. The plans and specifications

should be implemented correctly, and all specified quality control measures

should be followed. All substitutions or changes should be carefully analyzed

by the design professionals in terms of their seismic implications. Particular

attention should be paid to the proper bracing and anchorage of

nonstructural elements undergoing rehabilitation.

Continuity of Building Documentation

Assuring the continuity of building documentation is of particular importance

for incremental seismic rehabilitation. The rehabilitation of each individual

building may be staged over a period of several years or decades as discussed in Section B.2. The screening, evaluation, planning, and design may

be split among several engineering firms. Institutional memory may disappear as healthcare organization personnel, and even building ownership,

changes. It is therefore essential that the hospital facility manager document

all aspects and requirements of seismic rehabilitation from the earliest building screening through evaluation, seismic rehabilitation planning, and

completion of each increment of seismic rehabilitation, paying special attention to the scheduling of follow-up requirements and actions over time.

Fees for Professional Services

The professional services required to implement incremental seismic rehabilitation, as discussed above, clearly exceed the scope of traditional architectural/engineering design services. An appropriate fee structure for these new

services will need to be developed and integrated into the budgeting process.
Incremental Seismic Rehabilitation of Hospital Buildings

C-4

C.2 Discovering Integration Opportunities for

Incremental Seismic Rehabilitation

Introduction

In order to benefit from opportunities to integrate incremental seismic rehabilitation with other maintenance and capital improvement activities, it is

useful to discuss these activities as they are typically undertaken in

healthcare organizations. Most healthcare organizations are familiar with

their particular building inventories and the related patterns of maintenance

and capital improvement. A significant parameter of patterns of maintenance

and capital improvement is the category of the building in terms of the level

of care provided therein. Tertiary care is considered the highest level of care,

and includes the full range of technological and specialty care (such as open

heart surgery and cancer) in addition to a Level 1 Trauma Center with a list of

medical disciplines on site 24 hours per day. Secondary care is provided by a

facility such as a 20-bed rural hospital. Primary care is healthcare that can be

provided by “your primary care physician,” involving the lowest level of technology (for example, a long-term care facility).

Aggregate national data are of no particular relevance to a given organization, but may be of general interest and are summarized in the sidebar on the

opposite page.

Categories of Maintenance and Capital Improvement Projects

Healthcare organizations often categorize maintenance and capital improvement projects in the following ten categories:

1. Patient care improvements

2. New technology accommodation

3. Fire and life safety improvements

4. Roofing maintenance and repair/re-roofing

5. Exterior wall and window maintenance/façade modernization

6. Underfloor and basement maintenance and repair

7. Heating, Ventilating, and Air Conditioning (HVAC) improvements

8. Energy conservation/weatherization/air conditioning

9. Hazardous materials abatement

10. Building additions

These categories reflect groupings of building elements, administrative and

funding categories, or other parameters. Some healthcare organizations may

use other categorizations of maintenance and capital improvement work. The

purpose of this discussion is not to impose any specific categorization of

work, but simply to demonstrate the characteristics of a given item of

planned work that may make it especially suitable for integration with particular incremental seismic rehabilitation measures. These pairings of seismic

rehabilitation measures with other categories of work are referred to in this

section as “integration opportunities.” Facility managers using this manual

are encouraged to modify the work categories to suit their own practices.

In Brief

 Opportunities to

add seismic rehabilitation increments exist within

most major maintenance and capital

improvement activities.

 This section identifies these opportunities.
C-5

Part C

Work Descriptions and Matrices of Seismic Performance

Improvement Opportunities

Nine sections, C.2.1 through C.2.9, provide the facility manager with information used to identify incremental seismic rehabilitation opportunities that can

be combined with maintenance and capital improvement projects. The information becomes a tool, a technical framework or basis for action, that can be

communicated to the architect or engineer selected to work on any project

resulting from an integration opportunity.

These sections present the expanded descriptions of each of the work categories defined above in a consistent format. Each category is described in

terms of:

 General description

 Physical description

 Associated incremental rehabilitation work

 Performance of the work

 Special equipment

 Impact on building use

Matrices of possible specific integration opportunities, one matrix for each

work category (Tables C-1 through C-6), accompany the descriptions of the

first six categories of maintenance and capital improvement projects. These

include:

 Patient care improvements

 New technology accommodation

 Fire and life safety improvements

 Roofing maintenance and repair/re-roofing

 Exterior wall and window maintenance/façade modernization

 Underfloor and basement maintenance and repair

The integration opportunities for the next three categories of work are defined by reference to one or more of the six matrices.

Note that “building additions” is a special category of typical capital improvement. Additions, often of parking structures and storage structures,

have been made to many hospitals over the course of their useful lives.

Many hospital buildings constructed today are planned to accommodate

future additions, both horizontally and vertically. Current additions will be

designed to meet the seismic requirements of the building code. Additions

may also offer opportunities to strengthen an adjacent building or buildings.

These opportunities require careful design and analysis, and they are not

specifically identified in the integration opportunities matrices (Tables C-1

through C-6). Furthermore, inadequately designed additions, without proper

joints or connections to the existing building, could actually cause damage in

an earthquake, as different sections of the building pound against each other.

The seismic performance improvements shown in the matrices fall into three

categories:

 Indicates improvements that can be implemented when the

integration opportunity arises, on the basis of a quick evaluation by

a design professional. These types of improvements address

Generalized

Maintenance

and Capital

Improvement

Data

Whitestone Research (a

private market research

organization) indicates

that expenditures for

maintenance and repairs over a building’s

life exceed replacement

costs for most building

types and configurations including hospital

facilities.

The predominant categories of maintenance

and repair activities for

general hospitals are,

first, mechanical systems, followed by interior construction,

plumbing systems, interior finishes, and electrical systems. The only

other significant cost

repair category is roofing (only for low-rise

buildings). All these

activities offer opportunities for integration

with incremental seismic rehabilitation work.

The timing of the work

is also highly predictable. The top 8 years of

expense account for

about 50% of building

replacement. With regularity, years 10, 15, 20,

25, 30, 40, 45, and 50

are the highest expense

years, in roughly increasing order, with

year 50 incurring about

10.5% of replacement

costs for outsourced

repair and renovation

expenses.

These patterns suggest

significant opportunity

(and tendency) to

implement strategies

such as incremental

rehabilitation at specific

points over the service

life of a hospital building. They also imply

specific target periods

when the strategies

could most likely be

considered and implemented. Building age

becomes a very important characteristic for

incremental seismic

rehabilitation.
Incremental Seismic Rehabilitation of Hospital Buildings

C-6

deficiencies that may be identified in an ASCE 31, Seismic

Evaluation of Existing Buildings, Tier 1 analysis.

 Indicates improvements that can be implemented when the

integration opportunity arises and that require engineering design.

These types of improvements address deficiencies that may be

identified in an ASCE 31 Tier 1 or Tier 2 analysis.

 Indicates improvements that require engineering analysis to

determine if they should be implemented when the integration

opportunity arises to avoid unintentionally increasing the seismic

vulnerability by redistributing loads to weaker elements of the

structural system (sequencing requirements).

The absence of any of these symbols in a matrix cell indicates that the improvement in question is not applicable to the particular structural type. The

specific placement of each of these symbols (, , ) or the absence of a

symbol is based on professional judgment considering typical construction.

However, exceptions leading to changes in these categories may arise in specific buildings.

Integration opportunities for incremental seismic rehabilitation are a function

of three levels of seismicity: low, moderate, and high. The definitions of these

levels are those used in ASCE 31, Seismic Evaluation of Existing Buildings,

and FEMA 356, Seismic Rehabilitation of Buildings. They include both seismic

zonation and soil conditions. The soil conditions at the site may affect the

level of seismicity and must be taken into account. For example, soft soil may

amplify seismic forces on some buildings. The method for determining the

level of seismicity is given in Section 2.5 of ASCE 31. Significantly fewer seismic improvements are recommended for low levels of seismicity than for the

higher levels because seismic vulnerability is lower. The seismic improvements recommended for moderate and high levels of seismicity are the same

in number, but differ in the details of the improvements to reflect the different magnitudes of seismic loads encountered in the two levels.

Incremental seismic rehabilitation integration opportunities for each category

of work are a function of building structure type. This manual uses five broad

structural types, selected to be meaningful to hospital facility managers. The

materials used for the building’s vertical load-resisting system can be used to

categorize the following structural types:

 Wood

 Unreinforced masonry

 Reinforced masonry

 Concrete

 Steel

The latter two structural types, concrete and steel, are broken down further

into those with wood floors and roofs (flexible diaphragms) and concrete

floors and roofs (rigid diaphragms). This breakdown covers an important

parameter that determines how lateral loads are distributed to load-resisting

elements of the structures. Structures with flexible diaphragms distribute

earthquake loads based on proportional or tributary area between shearresisting elements (shear walls or frames). Flexible diaphragms allow a

straightforward analysis of loads in each shear element. Structures with rigid

diaphragms distribute earthquake loads based on the relative rigidity of the

individual shear-resisting elements. Rotational (twisting) forces may be introduced that must also be resisted by these and other elements. Rigid dia-
C-7

Part C

phragms require more detailed analysis that may have to be conducted for

each increment of the proposed strengthening program.

The facility manager using this section to identify incremental seismic rehabilitation integration opportunities in a particular building should use Sections C.2.1 through C.2.9 and the matrices therein as follows:

 Determine the category of maintenance or capital improvement

under consideration, and go to the section that corresponds most

closely to that category.

 Determine the level of seismicity applicable to the building by

considering the seismic map and the soil conditions, and identify

the applicable rows of the matrix.

 Determine which of the seven structural categories most closely fits

the building, and identify the applicable column of the matrix.

 List all the nonstructural and structural seismic improvements

identified in the matrix column and rows.

 Note the category of each improvement (, , or ).

The facility manager should present to the architect or engineer the annotated list of all the nonstructural and structural seismic improvements identified for consideration and inclusion in the respective scope of design work.

The architect or engineer should design the project using the companion

document, Engineering Guideline for Incremental Seismic Rehabilitation,

FEMA 420, which includes more detailed guidance on incremental seismic

design. The architect or engineer designing the incremental seismic rehabilitation program will most likely break down the seven structural type categories into further subcategories, as used in ASCE 31 or FEMA 356. These

categories and subcategories are discussed in detail in FEMA 420.

Definitions of Seismic Performance Improvements

The seismic performance improvements, both nonstructural and structural,

that are included in the matrices of integration opportunities described in the

preceding paragraphs and included in Sections C.2.1 through C.2.6, are all

extracted from a generic list of seismic performance improvements. The generic list is presented in Section C.2.10, which includes brief related explanations for each item on the list. The user of this manual can identify specific

seismic performance improvements in the respective project category matrices, and may then refer to these definitions for additional explanation of the

involved activities.

The generic nonstructural improvements in C.2.10 are numbered from 1 to 22

for ease of reference. The improvements selected from this list for inclusion

in each of the matrices in C.2.1 through C.2.6 are presented in the same order

and retain their respective number. This explains the occasional skipping of a

number when a specific nonstructural improvement is omitted because it is

not applicable in the particular matrix.

The generic structural improvements in C.2.10 are arranged in the order of

structural subsystems and elements. The improvements selected from this

list for inclusion in each of the matrices in C.2.1 through C.2.6 are presented

in the same order.
Incremental Seismic Rehabilitation of Hospital Buildings

C-8

C.2.1 Patient Care Improvements

General Description of the Work: Patient care improvements, in general,

are moving in the direction of outpatient care, which involves changes in the

character of interior spaces. Remodeling to improve patient care work has the

potential to involve any interior or exterior wall or element. This work may

involve simple work on a single wall or the entire space reconfiguration of

the patient areas in a hospital. The installation of conduit, cables, and wiring

to accommodate new communications technology may involve the

reconfiguration of concealed spaces under floors, above ceilings, and inside

wall cavities and chases located throughout the building.

Patient care improvements in tertiary care hospitals are often generated by

reorganization within specific departments. Other improvements may either

be included in the long-range strategic plans of the healthcare organization,

be required for Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation, or be triggered by federal, state, or health insurance mandates.

Physical Description of the Work: This work may include reconfiguration

of spaces and creation of new spaces anywhere in the building. Items include:

 Removing walls and ceilings

 Constructing new walls and partitions

 Installing replacement finishes

 Installing ductwork, piping, and communications networks

Access to spaces behind finishes and new wall construction provide various

opportunities for seismic rehabilitation work.

Associated Incremental Seismic Rehabilitation Work: Incremental seismic rehabilitation associated with this work may include adding or strengthening shear walls and bracing, improving beam/column connections and

diaphragm to wall anchorage, and adding or improving bracing and fastening of equipment.

Performance of the Work: This work is usually performed by skilled construction personnel employed by either the healthcare organization or a contractor. Usually architectural/engineering (A/E) design is used for major

remodeling.

Special Equipment: Special equipment required for access to work areas

for any seismic rehabilitation construction will typically be available during

any remodeling work.

Impact on Building Use: Major remodeling will require the space to be

vacated during the course of construction. However, some localized patient

care improvements may be carried out while the space is occupied.

Category 1

Patient Care

Improvements
C-9

Part C

V e ertical Load Carrying Structure

L f evel of

S y eimicity

W d y oo M y asonr 1 C e l oncrete S l tee

N * L umber* L M H

B g uilding

S l tructural

E t lement

S l tructural

S m t ub-System S t eismic Performance Improvement

N l onstructural

3   n/a n g /a Bracing and Detailing of Sprinkler and Pipin       

4   n/a n s /a Suspension and Bracing of Light       

5   n/a n s /a Fastening and Bracing of Ceiling       

6  n/a n g /a Anchorage and Bracing of Emergency Lightin       

7   n/a n s /a Attachment and Bracing of Cabinets and Furnishing       

8   n/a n/a Fastening and Bracing of Equipment (Mechanical

and Electrical)       

9   n/a n s /a Support and Detailing of Elevator      

10  n/a n s /a Bracing or Reinforcing Masonry Walls at Interior Stair      

11   n/a n k /a Attachment and Bracing of Large Ductwor       

13   n/a n s /a Restraint of Hazardous Materials Container       

14   n/a n ) /a Bracing of Interior Partitions (Masonry & Wood       

16  n/a n g /a Glazing Selection and Detailin       

17   n/a n r /a Underfloor Bracing of Computer Access Floo       

20   n/a n p /a Anchorage of Steel Stud Backu      

S l tructural

n/a   A t ll Collector and Drag Element Improvemen       

n/a   F s oundation Anchor Bolt 

n/a   F g oundation Cripple Stud Bracin 

n/a   F s oundation New Foundation 

n/a   Horizontal

Elements D g iaphragms Mezzanine Anchorage and Bracin      

n/a   Horizontal

Elements D s iaphragms Strengthening at Opening     

n/a   Horizontal

Elements D s iaphragms Strengthening at Re-entrant Corner       

n/a  Vertical

Elements L n oad Path Lateral Resisting System to Diaphragm Connectio       

n/a   Vertical

Elements

Braced

Frames Capacity/Stiffness    

n/a   Vertical

Elements

Braced

Frames Continuity    

n/a   Vertical

Elements

Braced

Frames Connections    

n/a   Vertical

Elements

Moment

Frames Beam Column Capacity/Stiffness    

n/a   Vertical

Elements

Moment

Frames Beam Column Connection    

n/a   Vertical

Elements S y hear Walls Capacit       

n/a   Vertical

Elements S y hear Walls Continuit       

n/a   Vertical

Elements S f hear Walls Extension of Wood Interior Walls to Roo   

n/a   Vertical

Elements S y hear Walls Lateral Stabilit      

n/a  Vertical

Elements

Out-of-Plane Anchorage of Concrete or Masonry

Wall      

* Nonstructural improvements are numbered for ease of use.

Structural improvements are not numbered, but rather, organized by structural element and sub-system.

 Work that may be included in the building rehabilitation/maintenance/repair project on the basis of a quick evaluation by a design professional

 Work requiring engineering design.

 Work requiring detailed engineering analysis and evaluation of sequencing requirements. The "x" designates work that could redistribute loads, overstressing

some elements.

Note 1: Masonry buildings with a concrete roof should use the concrete building, concrete diaphragm for options.

Table C-1: Patient Care Improvements

UnreinforcedMasonryReinforcedMasonryWoodDiaphragmConcreteDiaphragmWoodDiaphragmConcreteDiaphragm
Incremental Seismic Rehabilitation of Hospital Buildings

C-10

C.2.2 New Technology Accommodation

General Description of the Work: New medical technologies usually require more and different space. New technology accommodation work has

the potential to involve any interior or exterior wall or element. This category

may involve simple work on a single wall or the entire space reconfiguration

of a portion of the building such as a surgical suite or a laboratory. The installation of new equipment, ducts, pipes, conduit, cables, and wiring may involve the reconfiguration of concealed spaces under floors, above ceilings,

and inside wall cavities and chases located throughout the building.

The new technologies required in tertiary care hospitals are usually so extensive in scope that existing older buildings cannot accommodate them due to

inadequate ceiling heights and spatial relationships. In this case, the preferred solution is a building addition, with or without the demolition of part

of the existing building. The addition is required to comply with the building

code’s seismic requirements. Integration opportunities are minimal for the

existing portions of the building.

New technology accommodation in secondary and primary care hospitals

may be feasible within the existing building.

New technology accommodation is usually a major activity and is included in

the long-range strategic plans of the healthcare organization. Frequently this

work is in response to changing community healthcare requirements. It may

also be triggered by federal, state, or health insurance mandates.

Some codes may also require seismic rehabilitation when a building experiences a significant amount of damage in a disaster such as fire, flood, or

earthquake.

Physical Description of the Work: This work may include reconfiguration

of spaces and creation of new spaces anywhere in the building. Items include:

 Removing walls and ceilings

 Constructing new partitions

 Installing replacement finishes

 Installing ductwork, piping, and communications networks for new

technology

Access to spaces behind finishes and new wall construction provide various

opportunities for seismic rehabilitation work.

Associated Incremental Seismic Rehabilitation Work: Incremental seismic rehabilitation associated with this work may include adding or strengthening shear walls and bracing, improving beam/column connections and

diaphragm to wall anchorage, and adding or improving bracing and fastening of equipment.

Performance of the Work: This work is usually performed by skilled construction personnel employed by either the healthcare organization or a contractor. Usually A/E design is used for major remodeling.

Special Equipment: Special equipment required for access to work areas

for any seismic rehabilitation construction will typically be available during

any remodeling work.

Impact on Building Use: Major remodeling will require the space to be

vacated during the course of construction.

Category 2

New Technology

Accommodation
C-11

Part C

V e ertical Load Carrying Structure

L f evel of

S y eimicity

W d y oo M y asonr 1 C e l oncrete S l tee

N * L umber* L M H

B g uilding

S l tructural

E t lement

S l tructural

S m t ub-System S t eismic Performance Improvement

N l onstructural

3   n/a n g /a Bracing and Detailing of Sprinkler and Pipin       

4   n/a n s /a Suspension and Bracing of Light       

5   n/a n s /a Fastening and Bracing of Ceiling       

6  n/a n g /a Anchorage and Bracing of Emergency Lightin       

7   n/a n s /a Attachment and Bracing of Cabinets and Furnishing       

8   n/a n/a Fastening and Bracing of Equipment (Mechanical and

Electrical)       

9   n/a n s /a Support and Detailing of Elevator      

10  n/a n s /a Bracing or Reinforcing Masonry Walls at Interior Stair      

11   n/a n k /a Attachment and Bracing of Large Ductwor       

13   n/a n s /a Restraint of Hazardous Materials Container       

14   n/a n ) /a Bracing of Interior Partitions (Masonry & Wood       

16  n/a n g /a Glazing Selection and Detailin       

17   n/a n r /a Underfloor Bracing of Computer Access Floo       

20   n/a n p /a Anchorage of Steel Stud Backu      

S l tructural

n/a   A t ll Collector and Drag Element Improvemen       

n/a   F s oundation Anchor Bolt 

n/a   F g oundation Cripple Stud Bracin 

n/a   F s oundation New Foundation 

n/a   Horizontal

Elements D g iaphragms Mezzanine Anchorage and Bracin      

n/a   Horizontal

Elements D s iaphragms Strengthening at Opening     

n/a   Horizontal

Elements D s iaphragms Strengthening at Re-entrant Corner       

n/a  Vertical

Elements L n oad Path Lateral Resisting System to Diaphragm Connectio       

n/a   Vertical

Elements

Braced

Frames Capacity/Stiffness     

n/a   Vertical

Elements

Braced

Frames Continuity     

n/a   Vertical

Elements

Braced

Frames Connections     

n/a   Vertical

Elements

Moment

Frames Beam Column Capacity/Stiffness     

n/a   Vertical

Elements

Moment

Frames Beam Column Connection     

n/a   Vertical

Elements S y hear Walls Capacit       

n/a   Vertical

Elements S y hear Walls Continuit       

n/a   Vertical

Elements S f hear Walls Extension of Wood Interior Walls to Roo   

n/a   Vertical

Elements S y hear Walls Lateral Stabilit      

n/a  Vertical

Elements Out-of-Plane Anchorage of Concrete or Masonry Wall      

* Nonstructural improvements are numbered for ease of use.

Structural improvements are not numbered, but rather, organized by structural element and sub-system.

 Work that may be included in the building rehabilitation/maintenance/repair project on the basis of a quick evaluation by a design professional.

 Work requiring engineering design.

 Work requiring detailed engineering analysis and evaluation of sequencing requirements. The "x" designates work that could redistribute loads, overstressing

some elements.

Note 1: Masonry buildings with a concrete roof or floors should use the concrete building, concrete diaphragm for options. Unreinforced Masonry

ReinforcedMasonryWoodDiaphragmConcreteDiaphragmWoodDiaphragmConcreteDiaphragm

Table C-2: New Technology Accommodation
Incremental Seismic Rehabilitation of Hospital Buildings

C-12

C.2.3 Fire and Life Safety Improvements

General Description of the Work: Fire and life safety improvements may

involve the following building elements:

 Corridors and doors

 Stairs

 Lobbies

 Exits

 Alarm systems

 Standpipes

 Automatic fire sprinkler systems

In hospitals, this work will usually be scheduled as part of the normal planning process. Only if the work is in response to a disaster, such as a fire, will

the work be unplanned. However, a building disaster that requires some construction may provide an opportunity to integrate seismic safety improvements.

This category of work is usually mandated rather than routine. It may be

mandated by a JCAHO inspection, a fire marshal inspection, or other federal

or state agency, and it usually refers to the National Fire Protection Association (NFPA) Life Safety Code®. It may also be part of a general modernization

program. Some codes may also require seismic rehabilitation when a building experiences a significant amount of damage in a disaster such as fire,

flood, or earthquake.

Physical Description of the Work: Fire and life safety improvements usually involve the building’s means of egress, which will affect specific internal

spaces. Often the work is near the center of the building, such as in the corridors and stairwells. In some cases, it may affect spaces on the building perimeter, such as lobbies, entrances, and stairways. Items include:

 Removing and replacing corridor wall finishes, doors, transoms, and

equipment (e.g., cabinets) to provide access to walls and ceilings

 Installing new walls or altering existing walls at fire separations and

stairway enclosures

 Installing new stairways either within the building or on the exterior,

which may require removing part of a floor and constructing new walls

 Installing alarms, standpipes, or sprinklers to provide access to

concealed spaces

Associated Incremental Seismic Rehabilitation Work: Incremental seismic rehabilitation work associated with fire and life safety improvements

may include adding or strengthening shear walls and bracing, improving

beam/column connections and diaphragm to wall anchorage, and adding or

improving bracing and fastening of equipment.

Performance of the Work: Typically this work involves skilled construction

personnel. These may be healthcare organization personnel or contractors. In

some cases an A/E firm is involved.

Special Equipment: No special equipment is required for this task except

for scaffolding to provide access to the work areas.

Impact on Building Use: Typically this work must be carefully coordinated

and scheduled if done around occupants to preserve the comfort and safety

of patients and staff and to maintain staff efficiency.

Category 3

Fire and Life Safety

Improvements
C-13

Part C

V e ertical Load Carrying Structure

L f evel of

S y eimicity

W d y oo M y asonr 1 C e l oncrete S l tee

N * L umber* L M H

B g uilding

S l tructural

E t lement

S l tructural

S m t ub-System S t eismic Performance Improvement

N l onstructural

3   n/a n g /a Bracing and Detailing of Sprinkler and Pipin       

4   n/a n s /a Suspension and Bracing of Light       

5   n/a n s /a Fastening and Bracing of Ceiling       

6  n/a n g /a Anchorage and Bracing of Emergency Lightin       

7   n/a n/a Attachment and Bracing of Cabinets and

Furnishings       

8   n/a n/a Fastening and Bracing of Equipment (Mechanical

and Electrical)       

9   n/a n s /a Support and Detailing of Elevator      

10  n/a n/a Bracing or Reinforcing Masonry Walls at Interior

Stairs      

11   n/a n k /a Attachment and Bracing of Large Ductwor       

13   n/a n s /a Restraint of Hazardous Materials Container       

14   n/a n ) /a Bracing of Interior Partitions (Masonry and Wood       

16  n/a n g /a Glazing Selection and Detailin       

20   n/a n p /a Anchorage of Steel Stud Backu      

S l tructural

n/a   All

Elements Collector and Drag Element Improvement       

n/a   Horizontal

Elements D g iaphragms Mezzanine Anchorage and Bracin      

n/a  Vertical

Elements L n oad Path Lateral Resisting System to Diaphragm Connectio       

n/a   Vertical

Elements

Braced

Frames Capacity/Stiffness     

n/a   Vertical

Elements

Braced

Frames Continuity     

n/a   Vertical

Elements

Braced

Frames Connections     

n/a   Vertical

Elements

Moment

Frames Beam Column Capacity/Stiffness     

n/a   Vertical

Elements

Moment

Frames Beam Column Connection     

n/a   Vertical

Elements S y hear Walls Capacit       

n/a   Vertical

Elements S y hear Walls Continuit       

n/a   Vertical

Elements S f hear Walls Extension of Wood Interior Walls to Roo   

n/a   Vertical

Elements S y hear Walls Lateral Stabilit      

n/a  Vertical

Elements

Out-of-Plane Anchorage of Concrete or Masonry

Wall      

* Nonstructural improvements are numbered for ease of use.

Structural improvements are not numbered, but rather, organized by structural element and sub-system.

 Work that may be included in the building rehabilitation/maintenance/repair project on the basis of a quick evaluation by a design professional.

 Work requiring engineering design.

 Work requiring detailed engineering analysis and evaluation of sequencing requirements. The "x" designates work that could redistribute loads, overstressing

some elements.

Note 1: Masonry buildings with a concrete roof or floors should use the concrete building, concrete diaphragm for options. Unreinforced Masonry

ReinforcedMasonryWoodDiaphragmConcreteDiaphragmWoodDiaphragmConcreteDiaphragm

Table C-3: Fire and Life Safety Improvements
Incremental Seismic Rehabilitation of Hospital Buildings

C-14

C.2.4 Roofing Maintenance and Repair/Re-roofing

General Description of the Work: This category of work includes repair or

replacement of any or all of the following elements:

 Roof drainage system

 Eaves and fascias

 Flashing and vents

 Roofing membrane

 Insulation

 Walking surface and ballast

 Parapets and caps

 Roof-mounted equipment

 Roof deck

Most roof maintenance and repair work is done either in response to a failure

or as scheduled periodic maintenance or preventive maintenance work. Most

seismic rehabilitation integration opportunities for this work category will

relate to either scheduled or preventive maintenance. Placement of roofmounted equipment usually relates to other work categories such as new

technology accommodation, patient care improvements, or HVAC improvement.

In some jurisdictions, an application for a re-roofing permit triggers a code

requirement to implement specific seismic rehabilitation such as parapet

bracing.

Physical Description of the Work: Work on the roof may be localized to

specific areas, may extend to the entire perimeter of the roof, or may involve

the complete roof surface or large portions of it. Work may be limited to the

roofing membrane or may include work on the substrate, deck, and supporting system.

Associated Incremental Seismic Rehabilitation Work: Incremental seismic rehabilitation associated with roofing maintenance and repair may include strengthening diaphragms, improving diaphragm/wall connections,

bracing parapets and chimneys, and improving equipment attachment and

bracing.

Performance of the Work: Repair work on the roof is often performed by

hospital maintenance staff or healthcare organization staff. Outside contractors may be used for more extensive work.

An A/E firm is typically used in connection with the installation of mechanical,

electrical, telecommunication, or similar equipment. Also, healthcare organizations often use the services of an A/E for preparation of re-roofing specifications and bid documents.

Special Equipment: Scaffolding is sometimes used in connection with roof

work. Cranes or hoists may be used to lift materials or equipment.

Impact of Work on Building Use: Work on the roof generally does not

interrupt building use, except for complete re-roofing including the deck.

Work on rooftop equipment in hospitals may require shutting down specific

portions of the building.

Category 4

Roofing

Maintenance and

Repair/Re-roofing
C-15

Part C

V e ertical Load Carrying Structure

L f evel of

S y eimicity

W d y oo M y asonr 1 C e l oncrete S l tee

N * L umber* L M H

B g uilding

S l tructural

E t lement

S l tructural

S m t ub-System S t eismic Performance Improvement

N l onstructural

1  n/a n s /a Anchorage of Canopies at Exit       

2   n/a n t /a Anchorage and Detailing of Rooftop Equipmen       

11  n/a n k /a Attachment and Bracing of Large Ductwor       

12   n/a n/a Bracing of Parapets, Gables, Ornamentation, and

Appendages       

22   n/a n s /a Bracing or Removal of Chimney       

S l tructural

n/a   All

Elements Load Path and Collectors       

n/a   Horizontal

Elements D s iaphragms Attachment and Strengthening at Boundarie       

n/a   Horizontal

Elements D s iaphragms Strength/Stiffnes       

n/a   Horizontal

Elements D s iaphragms Strengthening at Opening     

n/a   Horizontal

Elements D s iaphragms Strengthening at Re-entrant Corner       

n/a   Horizontal

Elements D e iaphragms Topping Slab for Precast Concret    

n/a  Vertical

Elements L n oad Path Lateral Resisting System to Diaphragm Connectio       

n/a  Vertical

Elements

Out-of-Plane Anchorage of Concrete or Masonry

Wall      

* Nonstructural improvements are numbered for ease of use.

Structural improvements are not numbered, but rather, organized by structural element and sub-system.

 Work that may be included in the building rehabilitation/maintenance/repair project on the basis of a quick evaluation by a design professional.

 Work requiring engineering design.

 Work requiring detailed engineering analysis and evaluation of sequencing requirements. The "x" designates work that could redistribute loads, overstressing

some elements.

Note 1: Masonry buildings with a concrete roof should use the concrete building, concrete diaphragm for options.

UnreinforcedMasonryReinforcedMasonryWoodDiaphragmConcreteDiaphragmWoodDiaphragmConcreteDiaphragm

Table C-4: Roofing Maintenance & Repair/Re-roofing
Incremental Seismic Rehabilitation of Hospital Buildings

C-16

C.2.5 Exterior Wall and Window Maintenance/Façade

Modernization

General Description of the Work: Exterior wall and window maintenance

may involve the following activities:

 Pointing

 Patching

 Painting

 Caulking

This category of work may also include major projects such as:

 Window repair and replacement

 Refinishing with new cladding or material

Most exterior wall maintenance and repair work is done in response to failure or as scheduled periodic maintenance or preventive maintenance work.

Caulking and window repair and replacement are also often linked to energy

conservation/weatherization work.

Federal or state mandates that require energy conservation improvements

may lead to window repair or replacement.

Physical Description of the Work: Work is usually carried out throughout

an entire hospital, or hospital wing, as a scheduled maintenance activity,

although localized patching work is possible. Work may include:

 Repainting brick exterior walls

 Replacing windows

 Replacing curtain walls

 Improving energy conservation

Associated Incremental Seismic Rehabilitation Work: Strengthening of

shear walls and improvement of diaphragm/wall connections.

Performance of the Work: Exterior wall and window work may be performed by skilled construction personnel on the hospital or healthcare

organization’s staff or by an outside contractor. In many cases an A/E or curtain wall consultant may be involved to provide design, specifications, bid

process, and construction administration services.

Special Equipment: Access to higher exterior areas may require scaffolding

or swing stages. This access may provide economical opportunities for the

integration of seismic rehabilitation measures.

Impact on Building Use: Since most of the work is being performed from

the building exterior, it may be possible to accomplish the work at any time.

However, some of the seismic rehabilitation measures may be noisy or require access from the interior, so this work may have to be done when the

building, or wing, is vacant.

Category 5

Exterior Wall

and Window

Maintenance/Façade

Modernization
C-17

Part C

V e ertical Load Carrying Structure

L f evel of

S y eimicity

W d y oo M y asonr 1 C e l oncrete S l tee

N * L umber* L M H

B g uilding

S l tructural

E t lement

S l tructural

S m t ub-System S t eismic Performance Improvement

N l onstructural

1  n/a n s /a Anchorage of Canopies at Exit       

12  n/a n/a Bracing of Parapets, Gables, Ornamentation, and

Appendages      

15   n/a n s /a Shut-Off Valve       

16  n/a n g /a Glazing Selection and Detailin       

18  n/a n e /a Cladding Anchorag      

19   n/a n r /a Anchorage of Masonry Venee       

20   n/a n p /a Anchorage of Steel Stud Backu      

21   n/a n s /a Anchorage of Exterior Wythe in Cavity Wall      

S l tructural

n/a   All

Elements Collector and Drag Element Improvement       

n/a   F s oundation Anchor Bolt 

n/a   F g oundation Cripple Stud Bracin 

n/a   Horizontal

Elements D s iaphragms Attachment and Strengthening at Boundarie       

n/a  Vertical

Elements L n oad Path Lateral Resisting System to Diaphragm Connectio       

n/a   Vertical

Elements

Braced

Frames Capacity/Stiffness       

n/a   Vertical

Elements

Braced

Frames Continuity       

n/a   Vertical

Elements

Braced

Frames Connections       

n/a   Vertical

Elements

Moment

Frames Beam Column Capacity/Stiffness       

n/a   Vertical

Elements

Moment

Frames Beam Column Connection       

n/a   Vertical

Elements S y hear Walls Capacit       

n/a   Vertical

Elements S y hear Walls Continuit       

n/a   Vertical

Elements S y hear Walls Lateral Stabilit      

n/a  Vertical

Elements

Out-of-Plane Anchorage of Concrete or Masonry

Wall      

* Nonstructural improvements are numbered for ease of use.

Structural improvements are not numbered, but rather, organized by structural element and sub-system.

 Work that may be included in the building rehabilitation/maintenance/repair project on the basis of a quick evaluation by a design professional.

 Work requiring engineering design.

 Work requiring detailed engineering analysis and evaluation of sequencing requirements. The "x" designates work that could redistribute loads, overstressing

some elements.

Note 1: Masonry buildings with a concrete roof or floors should use the concrete building, concrete diaphragm for options. Unreinforced Masonry

ReinforcedMasonryWoodDiaphragmConcreteDiaphragmWoodDiaphragmConcreteDiaphragm

Table C-5: Exterior Wall and Window Work
Incremental Seismic Rehabilitation of Hospital Buildings

C-18

C.2.6 Underfloor and Basement Maintenance and Repair

General Description of the Work: Underfloor and basement maintenance

may involve the following activities:

 Repair of deterioration

 Repair of termite damage

 Equipment replacement

This work is most likely to be significant in smaller hospitals providing primary and possibly secondary care. In larger hospital and tertiary care facilities, basements are likely to be similar to any other floor, and underfloor and

basement work may therefore be much more extensive, closer in nature to

New Technology Accommodation.

Most underfloor repair activities will be in response to a problem. The solution may be immediate or assigned to the capital improvements budget. For

example, settlement and resulting underpinning repair may be the result of a

floor problem and require immediate intervention.

Usually there are no mandates or code issues involved with underfloor repair

work. Safety is the usual driving force.

Physical Description of the Work: Work includes:

 Replacing deteriorated wood elements

 Repairing cracked or bowed walls

 Repairing damaged or deteriorated floors, underpinning where

buildings have settled

 Replacing basement equipment

Associated Incremental Seismic Rehabilitation Work: Incremental seismic rehabilitation work associated with underfloor and basement work may

include adding cripple stud bracing, improving foundation anchorage, adding

new foundations, and improving floor to wall anchorage.

In the case of larger hospitals and tertiary care facilities, this work may include the incremental seismic rehabilitation work associated with C.2.2, New

Technology Accommodation. See Table C-2 in addition to Table C-6.

Performance of the Work: The work is often performed by healthcare organization staff or by outside contractors. Major design work will often require

A/E services.

Special Equipment: Special equipment is usually not required for

underfloor work. However, access to the area must be available.

Impact on Building Use: Except for equipment replacement, the work may

be done at any time, independent of building use.

Category 6

Underfloor and

Basement

Maintenance

and Repair
C-19

Part C

V e ertical Load Carrying Structure

L f evel of

S y eimicity

W d y oo M y asonr 1 C e l oncrete S l tee

N * L umber* L M H

B g uilding

S l tructural

E t lement

S l tructural

S m t ub-System S t eismic Performance Improvement

N l onstructural

8   n/a n/a Fastening and Bracing of Equipment (Mechanical

and Electrical)       

13   n/a n s /a Restraint of Hazardous Materials Container       

15   n/a n s /a Shut-Off Valve       

S l tructural

n/a   All

Elements Collector and Drag Element Improvement       

n/a   F s oundation Anchor Bolt 

n/a   F e oundation Anchorag       

n/a   F g oundation Cripple Stud Bracin 

n/a   F s oundation New Foundation       

n/a   F d oundation Pile Cap Lateral Loa      

n/a   F t oundation Uplif       

n/a  Vertical

Elements L n oad Path Lateral Resisting System to Diaphragm Connectio       

n/a   Vertical

Elements

Braced

Frames Connections  

n/a   Vertical

Elements

Moment

Frames Beam Column Connection  

n/a   Vertical

Elements S y hear Walls Capacit       

n/a   Vertical

Elements S y hear Walls Continuit       

n/a  Vertical

Elements

Out-of-Plane Anchorage of Concrete or Masonry

Wall      

* Nonstructural improvements are numbered for ease of use.

Structural improvements are not numbered, but rather, organized by structural element and sub-system.

 Work that may be included in the building rehabilitation/maintenance/repair project on the basis of a quick evaluation by a design professional.

 Work requiring engineering design.

 Work requiring detailed engineering analysis and evaluation of sequencing requirements. The "x" designates work that could redistribute loads, overstressing

some elements.

Note 1: Masonry buildings with a concrete roof or floors should use the concrete building, concrete diaphragm for options. Unreinforced Masonry

ReinforcedMasonryWoodDiaphragmConcreteDiaphragmWoodDiaphragmConcreteDiaphragm

Table C-6: Underfloor and Basement Work
Incremental Seismic Rehabilitation of Hospital Buildings

C-20

C.2.7 HVAC Improvements

General Description of the Work: HVAC improvements are often driven

by the changing needs for sterile environments, and thus are related to both

New Technology Accommodation and Patient Care Improvements. The installation of conduit, cables, wiring, ductwork, and HVAC equipment may involve

the reconfiguration of concealed spaces under floors, above ceilings, and

inside wall cavities and chases located in specific areas throughout the building.

Physical Description of the Work: The physical work involved in HVAC

improvements is likely to be localized. Items include:

 Installing HVAC equipment, which should meet the anchorage

requirements for seismic forces and may provide access to areas for

other work

 Installing ducts or piping to specific spaces

Associated Incremental Seismic Rehabilitation Work: This work may

include the incremental seismic rehabilitation work associated with the following other project categories discussed earlier:

 C.2.1, Patient Care Improvements

 C.2.2, New Technology Accommodation

See Tables C-1 and C-2 for integration opportunities.

Performance of the Work: The work may be performed by healthcare organization personnel or by outside contractors depending on the project size or

complexity. The services of an A/E will be required to ensure sterile environments.

Special Equipment: Special equipment may be required to provide access

to the work, including scaffolding or a crane or lift.

Impact on Building Use: Typically this work must be carefully coordinated

and scheduled if done around occupants.

C.2.8 Energy Conservation/Weatherization/Air Conditioning

General Description of the Work: Energy conservation/weatherization

and air conditioning projects may include the following items:

 Exterior envelope work

 Insulation

 Windows

 Electrical and HVAC equipment

 Ducts and piping

Building elements affected may include exterior walls, ceilings, attic spaces,

roofs, and basements.

These improvements may be in response to the healthcare organization’s

long-range strategic plan, special state or federal funding, or as part of other

routine equipment replacement. In all cases, the intent is not only to save

energy but also to reduce operating costs and improve occupant comfort.

Federal or state mandates may be factors leading to energy conservation

improvements. If special grants are available, they can be made part of the

capital improvement program. Local building code requirements may also

encourage energy conservation improvements.

Category 7

HVAC Improvements

Category 8

Energy

Conservation/

Weatherization/Air

Conditioning
C-21

Part C

Physical Description of the Work: The physical work involved in energy

conservation improvements may be localized or involve the entire building.

Items include:

 Improving or replacing windows

 Installing new insulation in exterior walls

 Installing new insulation in the attic, which may permit access to the

ceiling space

 Installing new insulation on the roof deck, which may be

coordinated with other roof-top work

 Installing HVAC equipment, which should meet the anchorage

requirements for seismic forces and may provide access to areas for

other work

 Adding air conditioning, which may include the installation of ducts

or piping to spaces throughout the building

Associated Incremental Seismic Rehabilitation Work: This work may

include the incremental seismic rehabilitation work associated with the following other project categories discussed earlier:

 C.2.1, Patient Care Improvements

 C.2.2, New Technology Accommodation

 C.2.4, Roofing Maintenance and Repair/Re-roofing

 C.2.5, Exterior Wall and Window Maintenance/Façade Modernization

See Tables C-1, C-2, C-4, and C-5 for integration opportunities.

Performance of the Work: The work may be performed by healthcare organization personnel or by outside contractors depending on the project size or

complexity. Whether the services of an A/E are required will depend on the

nature of the work.

Special Equipment: Special equipment may be required to provide access

to the work, including scaffolding or a crane or lift.

Impact on Building Use: Some of this work may be done at any time of

year from the roof. Most window or interior work must be accomplished

when the hospital is in use. Typically this work must be carefully coordinated

and scheduled if done around occupants in order to preserve the comfort and

safety of patients and staff and to maintain staff efficiency.

C.2.9 Hazardous Materials Abatement

General Description of the Work: The presence of hazardous materials

may involve abatement of:

 Asbestos

 Lead paint

 Radon

Most healthcare organizations have had asbestos abatement programs for

some time and radon programs more recently. Lead paint has also been recognized as a hazard for some time, but only recently has it been included in

government programs for abatement.

Hazardous materials abatement programs may be triggered by JCAHO accreditation requirements, federal requirements or mandates, or state regulations.

Category 9

Hazardous Materials

Abatement
Incremental Seismic Rehabilitation of Hospital Buildings

C-22

Physical Description of the Work: Hazardous materials abatement may

include the removal of finishes such as plaster, ceiling materials, and flooring

throughout the building. It may include removal of the adhesives used. Asbestos abatement may include the removal or encapsulation of insulation on

pipes and ducts. Lead paint abatement may include removal of the paint and

finishes or encapsulation of the component containing the lead paint. Radon

abatement may require installation of ventilation systems or other work in

the basement.

Associated Incremental Seismic Rehabilitation Work: In some cases,

the extent of the work may provide access to interior spaces that will provide

a seismic rehabilitation opportunity. Seismic rehabilitation work could follow

the hazard mitigation work before the finishes are reinstalled. This work may

include the incremental seismic rehabilitation work associated with the following other project categories discussed earlier:

 C.2.1, Patient Care Improvements

 C.2.2, New Technology Accommodation

See Tables C-1 and C-2 for integration opportunities.

Performance of the Work: The work is typically performed by specialty

contractors or specially trained healthcare organization staff.

Special Equipment: Special equipment, such as scaffolding, would often be

on the job as part of the abatement work. Other special equipment such as

fans and enclosures are irrelevant to seismic work.

Impact on Building Use: Building use will be curtailed during any hazardous materials abatement work. The work cannot be done around occupants. It

requires a vacant building or building wing.

C.2.10 Definitions of Seismic Performance Improvements

The seismic performance improvements included in the matrices of integration opportunities in Sections C.2.1 through C.2.9 are all extracted from the

generic list in the following tables. The table contains additional information

(description and purpose) that should be useful to hospital and healthcare

organization facility managers using this section.
C-23

Part C

Nonstructural Seismic Performance Improvements

H - ospitalN * umber*

L y evel of Seismicity D e efinitions and Purpose

L M H S e eismic Performance

I t mprovement D n escription P e urpose

1    Anchorage of Canopies at Exits Canopies or roofs over exits. Prevent collapse of canopies that would block exits and

possibly cause injuries.

2   Anchorage and Detailing of

Rooftop Equipment

Equipment should be properly attached,

and restrained if isolation-mounted.

Prevent equipment from sliding or falling off platforms

due to connection failure or non function.

3   Bracing and Detailing of

Sprinkler and Piping

Sprinkler pipes should be braced in each

direction.

Prevent sprinkler lines from breaking and flooding the

building.

4   Suspension and Bracing of

Lights

Lights may swing or otherwise fall in an

earthquake.

Prevent lights from falling and injuring occupants. Lights

should not be supported by a suspended ceiling in a

high or moderate seismic zone. Pendent lights should

have their sway limited.

5   Fastening and Bracing of

Ceilings

Diagonal bracing of ceiling. Suspended ceilings should be braced against sidesway

to reduce the chance of elements falling.

6    Anchorage and Bracing of

Emergency Lighting

Positive attachment of emergency lights. Prevent heavy battery packs from falling.

7   Attachment and Bracing of

Cabinets and Furnishings

Anchorage to structural walls or other

elements.

Prevent cabinets and other furnishings form toppling or

moving and causing damage. Fallen file cabinets may

block exit doors.

8   Fastening and Bracing of

Equipment (Mechanical and

Electrical)

Equipment above ceilings. Prevent fans and other equipment from swaying and

falling on occupants; connections could fail resulting in

equipment no longer functioning.

9   Support and Detailing of

Elevators

Elevator guides have become dislodged

in earthquakes. Applies to cable lift

elevators.

Keep elevators functioning.

10    Bracing or Reinforcing

Masonry Walls at Interior

Stairs

Interior exit stairs may have unreinforced

masonry enclosure walls that could

collapse.

Prevent collapse of walls blocking stairways.

11   Attachment and Bracing of

Large Ductwork

Large ducts. Prevent ducts from falling on occupants.

12    Bracing of Parapets, Gables,

Ornamentation, and

Appendages

Construct parapet bracing on the roof

side of the parapet. Gables are braced in

the attic space. Other elements are

anchored in a positive manner.

Prevent parapets, gables, and ornamentation from

falling outward.

13   Restraint of Hazardous

Materials Containers

Chemical labs, shops, etc. may have

materials that could, when combined,

create a fire or chemical hazard.

Reduce danger of breakage and mixing of chemicals.

14   Bracing of Interior Partitions

(Masonry and Wood)

Bracing may be vertical or diagonal

braces.

Interior partitions must be braced to prevent

falling/collapse.

15   Shut-Off Valves Installation of a shut-off device. Gas and water lines could break and should have a

means of turning them off.

16    Glazing Selection and Detailing Glass above a walking surface. Prevent exterior or interior glass from falling onto the

walking surface and causing injuries.

17   Underfloor Bracing of

Computer Access Floor

Raised floors for cabling. Prevent floors from collapsing and damaging

equipment.

18    Cladding Anchorage Heavy cladding (concrete) must be

connected to the structure.

Prevent cladding from falling. Careful design is required

so the cladding does not limit the structure's lateral

movement.

19   Anchorage of Masonry Veneer Veneer over exterior wood or masonry

walls or over other materials in steel or

concrete structure. Materials may be

brick, terra cotta, stone, or similar

materials.

Prevent inadequately anchored veneer from falling

outward on pedestrians.

20   Anchorage of Steel Stud

Backup

Steel studs behind veneer or other

cladding.

Prevent steel studs, used as a backup to support

veneer or other cladding, from becoming detached or

falling.

21   Anchorage of Exterior Wythe in

Cavity Walls

A masonry wall separated from the

veneer by a hollow space.

Prevent veneer from falling outward. Existing anchorage

should be checked for rust damage and loss of

strength.

22   Bracing or Removal of

Chimneys

Chimneys should be braced to the

structure.

Prevent chimneys from toppling into yards or through

roofs.

* Items numbered for ease of reference.
Incremental Seismic Rehabilitation of Hospital Buildings

C-24

Structural Seismic Performance Improvements

L y evel of Seismicity

B g uilding

E t lement

S l tructural

S - ub

S m yste

D e efinitions and Purpose

L M H S e eismic Performance

I t mprovement D n escription P e urpose

  Foundation Anchor Bolts Connection between the foundation

and the building.

Improve load path. Prevent building from sliding

off foundation.

  Foundation Anchorage Connection between the foundation

and the building for larger buildings.

Improve load path. Provide adequate

connection between building and foundation.

  Foundation Cripple Stud Bracing Short wood studs between the

foundation and the first floor.

Cripple studs are usually not braced. Prevent

them from toppling and causing the building to

fall off the foundation.

  Foundation New Foundations New foundations to convey loads. Additional foundations may be the preferred

solution in some cases.

  Foundation Pile Cap Lateral Load Piles supporting buildings may try to

move laterally from building loads

during earthquakes.

Brace piles at their top to eliminate the chance

of lateral movement and reduce chance of

foundation failure.

  Foundation Uplift Under overturning type loads,

foundations may be pulled upward.

Reduce the uplift chance by improving

foundation system; engineer should evaluate the

effects of uplift.

Definition Horizontal

Elements

Floors, mezzanines, and roofs.

Definition Horizontal

Elements

Diaphragms Floors and roofs connecting walls and

lateral force-resisting elements.

Diaphragms are the roof and floors of a

building. They must be of adequate strength to

transfer the earthquake loads to the walls and

other elements. The connection from the

diaphragm to the wall or other lateral forceresisting element is part of the load path.

  Horizontal

Elements

Diaphragms Attachment and

Strengthening at

Boundaries

Improving the connection of the

diaphragm to the edge/boundary

elements with nails, bolts, or welding.

This is part of the load path and conveys the

diaphragm forces into the walls or other lateral

force-resisting elements.

  Horizontal

Elements

Diaphragms Mezzanine Anchorage

and Bracing

Anchor the mezzanine to the wall.

Where there is an open side of the

mezzanine bracing may be necessary.

Make sure the mezzanine is attached to the

building to provide for a load path for the

mezzanine diaphragm and to reduce any

pounding of the mezzanine against the

building's walls or columns. A large mezzanine

may require bracing on the open sides.

  Horizontal

Elements

Diaphragms Strength/Stiffness Strengthen the diaphragm to limit its

lateral deflection.

Control the movement of the diaphragm to

reduce the damage due to drift and to control

the out-of-plane loads on vertical elements.

  Horizontal

Elements

Diaphragms Strengthening at

Openings

Strapping around diaphragm

openings.

Openings may create a weak point in the

diaphragm. Straps will provide additional

strength to wood diaphragms.

  Horizontal

Elements

Diaphragms Strengthening at Reentrant Corners"L" and "U" shaped buildings have

stress concentrations at the interior

corners.

Reduce damage from cracking and failures

caused by stress concentration.

  Horizontal

Elements

Diaphragms Topping Slab for

Precast Concrete

Concrete slab over precast concrete

roof to create a continuous

diaphragm. Connect to the vertical

elements as part of a load path.

Strengthen the roof to act as a lateral force

element. Controls drift of the roof or floor.

Definition Vertical

Elements

Braced

Frames

Steel or concrete beams and columns

with diagonal bracing.

Braced frames act as a lateral force-resisting

element. They are often used as the lateral

force-resisting element on open sides of

buildings. They must be connected to the

horizontal element as part of the load path.

  Vertical

Elements

Braced

Frames

Capacity/Stiffness Frame capacity improvements for

adequate load resistance.

Capacity and stiffness assure the adequacy of

the frame elements to resist loads.

  Vertical

Elements

Braced

Frames

Continuity Braced frames should be continuous

from the foundation to the roof.

Discontinuities of lateral force-resisting

elements create load transfer demands. Design

standards may impose higher loads for this

condition.

  Vertical

Elements

Braced

Frames

Connections The details of the connections, bolts,

or welds must be adequate.

Improvements to strength will not

have a negative effect on the phased

construction.

Braced frame connections assure the adequacy

of the frame elements to resist loads.

Improvements may be made by the addition of

steel plates with bolting or welding.

   Vertical

Elements

Load Path Lateral Resisting

System to Diaphragm

Connection

Connections between roof/floor and

wall or other element.

Permit earthquake loads to be conveyed to the

foundation—develop a load path. This is the key

element in seismic safety.
C-25

Part C

Structural Seismic Performance Improvements (continued)

L y evel of Seismicity B g uilding

E t lement

S l tructural

S - ub

S m yste

D s efinitions and Purpose of Structural Performance Improvements

L M H S e eismic Performance

I t mprovement D n escription P e urpose

Definition Vertical

Elements

Moment

Frames

A steel or concrete system of beams

and columns.

Moment frames act as a lateral force-resisting

element and brace the structure. They are often

used as the lateral force-resisting element on

open sides of buildings. They must be

connected to the horizontal element as part of

the load path.

  Vertical

Elements

Moment

Frames

Beam Column

Capacity/Stiffness

Frame capacity improvements for

adequate load resistance.

Capacity and stiffness assure the adequacy of

the frame elements to resist loads.

  Vertical

Elements

Moment

Frames

Beam Column

Connection

Steel or concrete with improved

connections to increase strength.

Improvements will not have a

negative effect on the phased

construction.

Beam column connections assure the adequacy

of the frame elements to resist loads.

Improvements may be made by the addition of

steel plates with bolting or welding.

Definition Vertical

Elements

Shear Walls Walls that brace the building against

earthquakes.

Shear walls brace the structure. Building walls

can act as lateral load-resisting elements. They

must be connected to the horizontal elements

as part of the load path.

  Vertical

Elements

Shear Walls Capacity Capacity equals strength. Capacity assures the adequacy of walls to resist

loads.

  Vertical

Elements

Shear Walls Continuity Shear walls should be continuous

from the foundation to the roof.

Discontinuities of lateral force-resisting

elements create load transfer demands. Design

standards may impose higher loads for this

condition. This is one of the most cost-effective

improvements in buildings.

  Vertical

Elements

Shear Walls Extension of Wood

Interior Walls to Roof

Extending interior wood walls to

diaphragms in unreinforced masonry

and other buildings.

Permit walls that were not constructed full

height to be used as shear walls in buildings

with wood interior walls.

  Vertical

Elements

Shear Walls Lateral Stability Tall walls may buckle and need

bracing.

Prevent buckling and possible wall collapse.

Walls must be anchored at the top or may have

other bracing elements such as diagonal or

vertical braces.

   Vertical

Elements

Out-of-Plane

Anchorage of

Concrete or Masonry

Wall

Connections from the walls to the

floors and roof.

Prevent walls from falling outward due to

inadequate connections between the wall and

the diaphragms. A cost-effective mitigation

measure for bearing wall buildings.

   All

Elements

Load Path and

Collectors

Distribute loads from diaphragms into

lateral force-resisting elements.

These are straps of steel or wood that "collect"

load and distribute it into the vertical lateral

force-resisting elements. Connections may be

with bolts, nails, or welding depending the

material and location.

App-1

Appendix

Appendix.

Additional Information

on Hospital Facility

Management

Introduction:

Typical Facility Management for Hospitals

The typical facility management process for existing hospital buildings consists of seven phases of activities: Acquisition, Current Building Use, Accreditation, Planning, Maintenance & Rehabilitation Budgeting, Maintenance &

Rehabilitation Funding, Maintenance & Rehabilitation Implementation, as

diagrammed in Figure 1. This process is sequential, progressing from left to

right in any given building. A healthcare organization that has a large inventory of buildings is likely to have ongoing activities in all of these phases.

This process is generic and, while local variations may occur, it is generally

followed by healthcare organizations, either explicitly or implicitly.

Figure 1: Typical

Management

Process
Incremental Seismic Rehabilitation of Hospital Buildings

App-2

Figure 2:

Management

Process

Influences

Both internal and external factors typically influence the hospital facility management process in its various phases. Internal factors (represented by up

arrows in Figure 2) are generated within the healthcare organization and its

administration. External factors (down arrows) are imposed on healthcare

organizations by outside entities.

This Appendix describes the activities and influences within each phase.

1. The ACQUISITION Phase of Hospital Facility

Management

Typical Process

Hospital acquisitions are a frequent feature of the healthcare delivery system

in the United States. Hospital buildings and their professional staffs will be

acquired as part of a single transaction. The due diligence process that precedes an acquisition is intended to identify, and quantify if possible, all the

liabilities or potential liabilities related to the asset being acquired.

A multi-discipline team that includes legal, risk management, and engineering carries out the due diligence. Because of the potential professional liabilities, legal questions are often the driving force in the process. The due

diligence process also involves a walk-through of the building. Environmen-
App-3

Appendix

Purchase Forms: Some healthcare organizations use internally generated

hospital purchase forms to guide their purchase decisions and related due

diligence. These forms are eclectic and developed over time. The forms may

focus on the facility age, equipment, and risk management history over a 5-

to 10-year period.

Seismic Consideration

A 5- to 10-year risk management history is unlikely to cover earthquake risks outside of California. In California, healthcare systems are

subject to Senate Bill (SB) 1953 that requires all California hospitals

to upgrade their facilities to allow their functioning after a large earthquake. The cost of compliance with SB1953 is likely to be the most

important factor in the purchase of existing hospital buildings and the

related due diligence.

tal risks, such as the presence of asbestos, are identified in the due diligence

process.

Influences and Related Seismic Considerations

As indicated in Figure 3, one internal factor (up arrow) influences acquisition

phase decision making. Figure 3:

Acquisition
Incremental Seismic Rehabilitation of Hospital Buildings

App-4

Figure 4:

Use

2. The Current Building USE Phase of Hospital Facility

Management

Typical Process

The current building use phase of the typical hospital facility management

process consists of four categories of activities and is influenced by significant internal and external pressures, as depicted in Figure 4.

Occupancy: This category of activity consists of all the functions that the

hospital is intended to shelter and to support. These include healthcare delivery, support, and ancillary functions. The healthcare delivery functions are

determined by demographic, sociological, anthropological, and other factors.

Support functions are administrative, and ancillary functions may be educational and community support.

These functions are carried out in each facility under the authority of the hospital director by the hospital staff. Each of these functions is subject to seismic risk and can be disrupted by seismic damage.

Hospitals are often characterized by the level of care provided therein. Tertiary

care is considered the highest level of care, and includes the full range of

technological and specialty care (such as open heart surgery and cancer) in
App-5

Appendix

addition to a Level 1 Trauma Center with a list of medical disciplines on site

24 hours per day. Secondary care is provided by a facility such as a 20-bed

rural hospital. Primary care is healthcare that can be provided by “your primary care physician,” involving the lowest level of technology (for example, a

long-term care facility). A regional hospital system will often include one tertiary care facility and several hospitals providing secondary and primary

care.

Operation: Facility operation consists of all the activities and functions that

the facility and its components must perform in order to support the occupancy. Examples are the mechanical functions (heating, cooling, ventilation,

and medical support functions), electrical functions (lighting, communications, alarm, and medical support functions), and plumbing functions.

Operation functions may be carried out by custodial staff of the healthcare

organization or the individual facilities and/or by contractors. Each of these

functions is subject to seismic risk and can be disrupted by seismic damage.

Maintenance: Maintenance includes all the activities required to enable the

occupancy and operation of the building to be carried out continuously over

time. They can be broken down into custodial maintenance, routine maintenance, and repair.

Maintenance functions may be carried out by custodial staff of the individual

facilities, by healthcare organization staff, and/or by contractors.

Facility Assessment: Facility assessment consists of the survey or inspection of the hospital facilities on a scheduled basis. It may also include a review of documents, such as archival building plans, for retrieving specific

information. The purpose of the surveys or inspections is to determine facility

conditions in relation to one or more of the following categories:

 user complaints

 maintenance needs

 preventive maintenance needs

 specific environmental hazards

 asbestos

 lead paint

 lead

 radon

These surveys are carried out by the individual hospital facility staff, with

possible participation by central healthcare organization staff. In some cases

surveys are carried out by a state or local fire marshal, an insurance company, or other outside entity. The surveys may or may not be coordinated as

to schedule, content, personnel, etc. Healthcare organizations may or may

not use prepared inspection forms or checklists. Finally, healthcare organizations may vary as to the extent and specific nature of their record keeping

and reporting.

Influences and Related Seismic Considerations

As indicated in Figure 4, five external factors (down arrow) and one internal

factor (up arrow) influence current building use phase decision making.

State Licensure: External state licensure regulations establish requirements

affecting the building use phase, which have implications for facilities. The

Rules and Regulations for Licensure of Hospitals in Virginia, for example,

require a licensure survey of hospital buildings every 18 to 24 months.

 structural hazards

 fire/life safety

 environmental quality

 energy use/conservation

 accessibility

 other
Incremental Seismic Rehabilitation of Hospital Buildings

App-6

Seismic Consideration

Currently there are no seismic rehabilitation mandates or implications

in any state programs related to hospitals outside of California. In

California, healthcare systems are subject to SB1953 that has established three interim milestone dates (January 1, 2002; January 1, 2008;

and January 1, 2030) for progressively bringing all hospital buildings

into full compliance with the seismic requirements of California Building Codes by January 1, 2030.

Health Insurance: External private health insurance programs establish

requirements for healthcare delivery. These requirements may have facility

management implications.

Seismic Consideration

Private health insurance requirements are unlikely to impose any seismic considerations on hospitals.

Property and Liability Insurance: External private property and liability

insurance companies often require surveys or inspections of hospital facilities on an annual or other scheduled basis.

Seismic Consideration

Property insurers are unlikely to recommend extensive seismic improvements outside of California. In Utah, for example, they have recommended seismic bracing of sprinklers as part of the life safety

systems, but no other improvements.

Federal and State Programs: Various external programs may establish

requirements affecting use of a healthcare organization’s facilities (e.g.,

Americans with Disabilities Act [ADA] and Occupational Safety and Health

Administration [OSHA] requirements). Additionally, governmental funding

programs may impose facility requirements (e.g., Medicare reimbursements

and energy conservation).

Seismic Consideration

Currently, there are no seismic rehabilitation mandates or implications in any federal or state programs related to hospitals, with the

exception of California.

Specific surveys or inspections may be mandated by external federal, state,

or local laws/programs. In Virginia, for example, fire marshal surveys of hospitals are carried out annually. These surveys/inspections may be carried out

by a variety of entities:

 Federal personnel (e.g., from OSHA, Environmental Protection

Agency [EPA])

 State/city/county personnel (e.g., fire marshal, code enforcement,

environmental, health)

 Healthcare organization personnel (e.g., custodial or facility

managers)

 Hospital building contracted personnel (e.g., asbestos inspectors)

 Consultants

Seismic Consideration

Currently, there are no seismic survey or inspection mandates or implications in any federal or state programs related to hospitals, with

the exception of California.

Emergency Management: External state or local emergency management

agencies may assign specific roles that hospitals must perform in case of

natural disasters, including earthquakes. This may affect the occupancy phase

by requiring periodic exercises involving building occupants.
App-7

Appendix

Figure 5:

Accreditation

Seismic Consideration

Local emergency management plans related to the role of hospitals in

a disaster may be general and broad, or detailed and specific. In some

cases, specific hospitals are assigned a specific function they are to

perform in the post-disaster environment. In such cases a legitimate

question is “In what condition will the building in question be following an earthquake?” Answering this question requires some form of

seismic inspection, evaluation, and possible mitigation.

Complaints by Occupants: Internal complaints by occupants (patients and

staff) are a potentially significant pressure on the facility management process.

Seismic Consideration

The extent of complaints about seismic vulnerability generated by hospital occupants is not known. Safety concerns of hospital staff in Utah

have reportedly included seismic safety.

3. The ACCREDITATION Phase of Hospital Facility

Management

Typical Process

The accreditation phase of the typical hospital facility management process

consists of a variety of evaluation and inspection activities and is influenced

by external pressures, as depicted in Figure 5.
Incremental Seismic Rehabilitation of Hospital Buildings

App-8

Typical Process

Joint Commission on Accreditation of Healthcare Organizations

(JCAHO) Assessment: JCAHO provides voluntary accreditation to

healthcare organizations including hospitals. The Commission has been accrediting hospitals for more than 40 years. Its accreditation is a nationwide

seal of approval that indicates a hospital meets high performance standards.

Despite its voluntary nature, this accreditation is, de facto, mandatory in

most states, because all federal payments and reimbursements, including

Medicare and Medicaid payments, are made to only JCAHO-accredited organizations. Some states, including Utah, have alternative accreditation programs that are recognized by the federal government.

JCAHO accreditation is done on a 3-year cycle. Every 3 years a hospital is

assessed for compliance with JCAHO accreditation standards.

Influences and Related Seismic Considerations

As indicated in Figure 5, one external factor (down arrow) influences accreditation phase decision making.

Accreditation Procedures: JCAHO accreditation is a critical external factor

that influences hospital operations, including facility management. The procedures of JCAHO accreditation of hospitals are covered in the Comprehensive Accreditation Manual for Hospitals, which includes EC3.2.1 – Designing

the Environment of Care. EC3.2.1 contains many standards that address

building performance, including compliance with NFPA 101, Life Safety

Code©.

Environment of Care (EC) standards EC.1.4 and EC.2.4, amended and expanded in January 2001, require hospital, ambulatory care, behavioral

health, home care, and long term care organizations to develop and implement a management plan that ensures effective response to emergencies

affecting the delivery of healthcare. It requires the emergency management

plans to address the following four phases of emergency management activities:

 Mitigation

 Preparedness

 Response

 Recovery

The JCAHO defines “emergency” as:

“a natural or manmade event that suddenly or significantly:

 disrupts the environment of care (for example, damage to the

organization’s buildings and grounds due to severe windstorms,

tornadoes, hurricanes, or earthquakes);

 disrupts care and treatment (for example, loss of utilities due to

floods, civil disturbances, accidents, or emergencies within the

organization or in its community); or

 changes or increases demands for the organization’s services (for

example, bioterrorist attack, building collapse, or airplane crash in

the organization’s community).”

The official JCAHO newsletter, Perspectives, dated December 2001, includes

the following discussion of mitigation:
App-9

Appendix

“Mitigation activities lessen the severity and impact of a potential emergency. Mitigation begins by identifying potential emergencies (hazards) that

may affect the organization’s operations or the demand for its services, followed by implementing a strategy that supports the perceived areas of vulnerability within the organization.”

Standard EC.2.9.1 requires organizations to execute the emergency management plan by conducting emergency management drills.

The American Society for Healthcare Engineering (ASHE) has developed a

tool, entitled Hazard Vulnerability Analysis,1 to help organizations develop an

emergency management plan. It is a simple matrix that lists a variety of hazards, including earthquake, and requires the rating of each in terms of its

probability (on a 4-point scale from “none” to “high”), risk (on a 5-point scale

from “low disruption” to “life threat”), and preparedness (on a 3-point scale

from “poor” to “good”). The values on each scale are multiplied to arrive at a

total value for each hazard. The tool instructs: “Determine a value below

which no action is necessary. Acceptance of risk is at the discretion of the

organization.”

Seismic Consideration

Earthquake damage to hospitals is specifically noted in both the JCAHO

standard and in the ASHE tool as a potential hazard to be addressed in

the management plan. This document, Incremental Seismic Rehabilitation of Hospital Buildings, can be used in developing the management plan.

4. The PLANNING Phase of Hospital Facility

Management

Typical Process

The planning phase consists of projecting and forecasting future needs. It

can be carried out periodically or continuously, and it may vary as to the time

period covered by the projections and forecasts. Planning functions may be

carried out by the hospital administration as well as central healthcare organization staff, with or without the assistance of consultants. Planning consists

of two separate but related activities—healthcare planning and facility planning—and is affected by both external government and health insurance requirements and internal board policies, as depicted in Figure 6.

Healthcare Planning: Healthcare planning attempts to formulate future

healthcare delivery programs and their support needs by analyzing and forecasting several factors, such as:

 demographics (population growth or decline, neighborhood shifts,

etc.)

 healthcare philosophy

 medical technology

 cultural and socioeconomic factors

 federal and state mandates

 equity and civil rights

1 Healthcare Facilities Management Series, Management Monograph #055920, Susan B.

McLaughlin, February 2001, ASHE of the American Hospital Association.
Incremental Seismic Rehabilitation of Hospital Buildings

App-10

Figure 6:

Planning

A national trend in healthcare planning is the movement toward outpatient

care, driven by health insurance and best-practice medical care.

Healthcare planning is generally carried out by the central healthcare

organization’s staff. However, specific medical service improvements are generated by hospital department heads who suggest reorganization within their

respective departments.

Facility Planning: Facility planning consists of preparing long-range facility

plans, strategic facility plans, or a similar document. It combines the products

of three distinct activities—the healthcare plan, the facility assessment, and

the JCAHO accreditation (see Figure 6)—into a detailed projection of facility

requirements. Thus, it is a product of the combined efforts of individual hospital staff and central healthcare administration staff. The projection may

cover a defined time frame, such as 5 years.

Different organizations may use different classifications of projects in their

facility plans, reflecting a variety of legal, administrative, jurisdictional, and

other factors. However they may be classified, a comprehensive facility plan

should include the following elements:
App-11

Appendix

 New construction

 Additions to existing buildings

 Renovations of existing buildings

 Building systems replacements

 Building systems repairs

 Scheduled maintenance

 Preventive maintenance

 Building disposition (change of use, sale, demolition)

The plan will identify the time frames in which each project is to be accomplished, and it may include cost estimates. Some experts have conceptualized the facility plan as consisting of four general categories, which may

provide guidance for budgeting:

 Physical plant renewal

 Physical plant adaptation

 Catch-up maintenance

 New construction

If effective, the facility plan will be used as a budgeting tool and will provide

direct inputs into the budget process. It should be revised and updated on a

routine basis to reflect:

 Changes in the healthcare delivery plan

 Revised facility assessments

 Budgeting and funding realities

Influences and Related Seismic Considerations

As indicated in Figure 6, two external factors (down arrow) and one internal

factor (up arrow) influence current planning phase decision making.

Board Policies: In terms of internal influences, healthcare organization

boards may occasionally adopt written policies on issues of political and social significance that can affect both healthcare and facility planning. These

policies guide the actions of the healthcare organization.

Seismic Consideration

Boards may adopt policies addressing seismic issues, including seismic performance objectives and rehabilitation of hospital buildings,

either as a one-time task or a recurring incremental program.

Government Mandates: Federal, state, and local government agencies

have historically established external requirements affecting the planning

phase as regards both healthcare delivery planning and facility planning.

These requirements may have facility rehabilitation implications. Some of

these requirements may be accompanied by funding, perhaps providing an

opportunity to integrate disparate objectives into coordinated actions.

Seismic Consideration

Currently, federal or state programs do not include seismic rehabilitation mandates or implications applicable to non-federal hospitals, with

the exception of California.

Health Insurance: Health insurance programs, both federal (Medicare and

Medicaid) and private, establish external requirements affecting the planning
Incremental Seismic Rehabilitation of Hospital Buildings

App-12

Figure 7:

Budgeting

phase with regard to healthcare delivery planning, and possibly facility planning as well. Medicare depreciation schedules are one example of the latter.

Seismic Consideration

Currently, no seismic rehabilitation mandates or implications exist in

any health insurance programs.

5. The Maintenance and Rehabilitation BUDGETING

Phase of Hospital Facility Management

Typical Process

The budgeting phase consists of the projection of future financial resources

required to meet future needs. It is carried out annually (covering a period of

one or more years). Each hospital director initiates the budgeting phase with

input from the respective hospital engineering department and safety officer.

Organization-wide, the vice president for facilities services oversees the budget development. The facility budget is a process that can be thought of as

percolating up through the organization. It is affected by externally influenced risk management policies and internal budget constraints, as depicted

in Figure 7.
App-13

Appendix

Three elements of the budget are relevant to the discussion of facility management:

 Capital

 Maintenance

 Insurance

Capital Budgets: Capital budgets generally relate to the acquisition of

buildings and major systems and to major additions to existing buildings, the

occurrence of which is not annual or repetitive and which can therefore be

amortized. The distinction between capital and maintenance budgets may

vary among different healthcare organizations. At one extreme is a total

separation, mandated by law, labor jurisdiction, or other factors. At the other

extreme is a rather unclear separation between the two funding mechanisms.

Maintenance Budgets: Maintenance budgets generally relate to recurring

annual expenditures and address existing inventories of buildings and systems without adding to the inventories. Maintenance activities are often part

of operations budgets or general fund budgets.

Insurance Budgets: Financial resources earmarked for insurance may be

used in different ways, including the purchase of third-party insurance, the

contribution to a regional or statewide risk and insurance pool, and/or the

funding a self-insurance reserve. Property and general liability insurance are

relevant to facility management considerations.

Influences and Related Seismic Considerations

As indicated in Figure 7, two internal factors (up arrow) influence budgeting

phase decision making.

Budgetary Constraints: Internally, political and economic conditions may

place limits on hospital budgets. The problem is often exacerbated by unfunded mandates imposed on healthcare organizations by federal and state

agencies.

Seismic Consideration

The strategy of integrating incremental seismic rehabilitation with

other work, which is an integral part of this facility and financial management model, can provide a method for addressing seismic risk reduction within budget constraints. See full discussion of this

opportunity in Section B.2.2.6, Seismic Rehabilitation Planning for

Specific Buildings.

Risk and Insurance Management: The healthcare organization’s risk and

insurance management requirements, developed in response to external

insurance influences, may have a direct or indirect role in the budget phase

of the process regarding the decisions related to insurance. Medicare, for

example, sets limits on capital and operating budgets and establishes detailed depreciation schedules, which influence levels of reimbursement.

Seismic Consideration

In areas of seismic hazard, the risks of building loss or damage, occupant death or injury, and healthcare organization liability must all be

assessed. It must be decided whether to seek earthquake property

and casualty insurance coverage and general liability coverage. Insurance companies that offer such coverage do not usually offer incentives to customers to undertake loss reduction measures in the form

of seismic rehabilitation. However, this situation might change, and

the question may be subject to negotiation.
Incremental Seismic Rehabilitation of Hospital Buildings

App-14

6. The Maintenance and Rehabilitation FUNDING

Phase of Hospital Facility Management

Typical Process

The funding phase consists of obtaining the financial resources to meet hospital needs. The funding of hospital budgets in general, and of the three budget elements of capital, maintenance, and insurance, varies from one

healthcare organization to another. Funding is influenced externally by regional and local economic conditions, federal and state programs, and bond

financing regulations, as depicted in Figure 8.

States vary widely in their contribution to local hospital budgets. Some states

limit their contribution to capital budgets and others to a general fund.

Healthcare organizations can fund their budgets by various combinations of

the following sources: revenue from operations, interest income, debt (bond

financing), and taxation (in the case of public hospitals). The latter (debt and

taxation) are in some cases controlled or limited by state constitutions or by

periodic voter initiatives. Different hospital budgets may be subject to varying requirements of approval of taxation and/or debt by the electorate.

There are many local variations in funding where healthcare organizations,

municipalities, and counties have overlapping jurisdictions.

Influences and Related Seismic Considerations

As indicated in Figure 8, three external factors (down arrow) influence funding phase decision making.

Figure 8:

Funding
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Appendix

Regional and Local Economic Conditions: Externally, the funding of

hospital construction is subject to local and national socio-economic conditions well beyond the control of the healthcare organization. Construction

funding depends on interest rates, the region’s and organization’s bond rating, and similar parameters.

Seismic Consideration

Even though seismic rehabilitation is clearly a risk reduction activity,

there is no evidence that any healthcare organization has improved

its bond rating as the result of undertaking seismic mitigation activities of any kind.

Federal and State Programs: The funding of hospital construction and

rehabilitation may be subject to federal and state programs beyond the control of the healthcare organization.

Seismic Consideration

While these programs are not likely to address seismic rehabilitation,

they should be taken full advantage of for seismic rehabilitation purposes.

Bond Financing Regulations: Local administrative procedures and structure in place to obtain bond financing will have a significant impact on the

ability of a healthcare organization to achieve its objectives, regardless of

whether they include seismic risk reduction or not. Certain types of expenditures out of the proceeds of a bond issue, such as operations or maintenance, may be prohibited by the conditions of the bond.

Seismic Consideration

Some seismic rehabilitation increments may be classified as repair or

maintenance work, and thereby be precluded from a capital improvement bond. As explained in Section B.2.2.9, Seattle Public Schools used

two types of bonds (Capital Levy Bonds and Capital Improvement

Bonds) to cover the funding of its incremental seismic rehabilitation

program in response to Washington state law.

7. The Maintenance and Rehabilitation

IMPLEMENTATION Phase of Hospital Facility

Management

Typical Process

The implementation phase includes design and construction and can be broken into four categories of projects, of which the latter three are relevant to

existing buildings:

 New building construction projects

 Building acquisition projects

 Capital improvement projects

 Maintenance projects

The implementation phase is primarily affected by external federal and state

programs and building code requirements, as depicted in Figure 9.

Acquisition of existing buildings is discussed above as the first phase of the

facility management process.

Capital improvement and maintenance projects are managed by healthcare

organization or individual hospital staffs, and carried out by these staffs and

by contractors. The management of these two categories may be separated

or combined, depending on issues of labor jurisdiction and legal authority.
Incremental Seismic Rehabilitation of Hospital Buildings

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Influences and Related Seismic Considerations

As indicated in Figure 9, two external factors (down arrow) influence implementation phase decision making.

Federal and State Mandates and Programs: Externally, federal and state

programs may establish requirements affecting the implementation phase

(e.g., ADA and OSHA requirements). Additionally, governmental funding programs may mandate requirements for facilities in participating healthcare

organizations (e.g., energy conservation).

Seismic Consideration

Currently there are no seismic rehabilitation mandates or implications

in any federal programs related to existing non-federal hospitals.

Codes and Code Enforcement: Also externally, building codes, as well as

the Life Safety Code©, impose requirements on the implementation phase, in

cases of repair, alteration, or addition to existing buildings. These requirements may be enforced by a state or local agency, or there may be a requirement that hospital building staff be responsible for their enforcement. Such

requirements can add costs to a project and jeopardize feasibility, unless

done incrementally.

Seismic Consideration

Codes do not mandate seismic rehabilitation in repair and alteration

projects, though additions must comply with building code seismic

requirements. Incremental seismic rehabilitation is consistent with

most building code requirements applicable to existing buildings.

Figure 9:

Implementation