Seismic Safety Inspection Checklist for Health Tourism Patient Care Facilities

Health tourism patient care facilities deserve special attention with respect to seismic safety because their occupants tend to be vulnerable, (ill, injured, post-operative, intra-operative, children) non-residents who don’t know their way around the area.

By Maria Todd, PhD MHA
Executive Director, Center for Health Tourism Strategy

Every day there are new companies formed to coordinate care for patients engaged in medical or dental tourism and other health travel. Some have opened their business to assume the role of specialized coordinators – travel agents – and other “facilitators”. Often they have little to no experience, training or education from within the healthcare industry when they startup. Others may have been in some role in healthcare, but the role didn’t really come with responsibilities for health facility assessment and site evaluation.

New health tourism and medical travel business owners may have been a wheelchair orderly, a doctor or a visiting consultant, a nurse, or some other patient care technician or technologist, an insurance biller, and admissions, or discharge clerk, or even a cashier or phlebotomist.  As such, no one may have shared this education and training with them – which can result in not even knowing what they don’t know.

Notwithstanding the foregoing, this information is critical to anyone assigned the role of quality management and patient safety for the company. As part of the due diligence and vetting of a health tourism or health travel patient care facility or accommodation (in which a standard hotel or other alternative accommodation is used to house and keep safe “vulnerable visitors” who are ill, injured, post-operative, intra-operative, or children or the frail and elderly who are non-residents and who may not know know their way around the area to move to safety or to “shelter in place.”

Many individuals, business owners and construction developers tend to associate earthquakes in high-frequency, earthquake areas. They are unaware that earthquakes are global hazard. As a “referral” agent or “facilitator” your professional responsibility does not end with a “disclaimer form”. Your form may indicate that choice of facility or destination is the patient/customer’s risk”. 

But in reality, one can argue that when you engage in a business to “facilitate, advise, guide, refer, or influence others” and you negotiate to receive “money for good and valuable consideration (payment for your time and expertise), the receipt and sufficiency of which is hereby acknowledged,…you have responsibility to “be” a professional. That translates to adequate and proper pre-inspection so that you don’t “negligently refer” a client expecting professional service and guidance in exchange for payment of your fee. 

If you don’t pre-inspect and assess risks and you are paid a fee for your professional services, you are a pure referral broker and your risk of professional negligence is increased to a level that few underwriters will agree to accept risk for your business practices. And believe you me, your disclaimer form most likely won’t protect you from neglecting to do the essential due diligence before adding a hospital, clinic, or accommodation to your approved “provider network” in the first place if they didn’t measure up to basic fitness for duty.

Seismic safety should be on any facilitator’s checklist, and evidence of due diligence should be a part of your files, and updated periodically or when the subject facilities expand or remodel, and also as part of your internal quality management system. Notifications of expansions and remodeling should be a criteria in your network participation agreement, and in lieu of your personal assessment and inspection, you could ask for a copy of an Engineer’s Statement of Seismic Safety or some equivalent document to show you at least checked and were concerned, should the unthinkable occur.

Health care facility and accommodation designs present special problems:

  1. Health care facilities often are densely occupied buildings in use around the clock. In addition to patients, who may be surrounded by equipment using potentially hazardous gases, these facilities are occupied by staff, medical personnel, and visitors.
  2. Health care facilities often are extremely complex buildings combining the functions of a hotel, office, laboratory, and warehouse. They feature many small rooms that are occupied by individuals who are relatively unfamiliar with the overall layout of the facility.
  3. Many health care facility supplies are essential for patient survival and are crucial for treatment of earthquake victims. Patient records also are vital for accurate treatment.
  4. Health care facility and hotel resort functions are dependent on utilities such as power, water, waste disposal, and communications to a far greater degree than are most other types of facility. 
  5. Large health care facilities and hotels and resorts also rely on elevators for moving people and supplies and, after even a moderate earthquake, elevator operation will cease until the equipment can be inspected for damage.
  6. Some of the contents of health care facilities and hotel resorts can be hazardous if overturned or damaged, and drugs can become a target for abusers if security breaks
    down.
  7. After an earthquake, community damage will result in an influx of injured people and friends and relatives seeking information about patients. In addition, at a time of great need, the building may be nonfunctional and trained staff killed or injured.

Predictive Risk Models Aren’t Accurate Yet

Science and technology have not yet generated a technique for accurately predicting when an earthquake will occur. Earthquakes are a natural hazard even more difficult to deal with from a life safety standpoint than hurricanes or floods since one has no relatively immediate warning and cannot evacuate the area. 

However, geologic studies on a nationwide basis are rapidly advancing knowledge on the probability and nature of future earthquakes. These studies eventually should provide a more precise basis for establishing the relationship between seismic risk and appropriate seismic design.

The way in which healthcare treatment facilities and hotels or resort buildings are designed and constructed ultimately determines the probability and extent of earthquake damage, and observation and experimentation have generated a considerable amount of information on effective seismic-resistant design and construction.

As a result of the study of buildings in and after earthquakes and experimental
research in laboratories, where structures can be shaken to simulate the effects
of earthquakes, a great deal is known about the relative safety of different types
of construction. But many medical tourism destinations are exploited for medical tourism treatment because of the ability to exploit price arbitrage. For example a gallbladder removal or hernia repair or open heart surgery are essentially the same from first incision to final suture and wound dressing. 

In a knee replacement surgery, however, ligament balancing and alignment of bones and joints can be affected by 2° margin of error. Without robotics-assisted technology, a knee replacement being done by conventional means is already at risk of a greater than 2° margin of error. It is beyond most surgeon’s control range to correct to that degree. But add a wiggle or two during a small seismic event and what can happen to the entire arthroplasty? With the robot, you can recalibrate and perform the cuts and balancing in virtual reality first before working on the patient. That’s not possible (or likely) in a place that has no robot and hasn’t been seismically updated to current best standards. Is your patient aware that that is what they are trading for the sake of a lower price?

Therefore, if one elects a remote, undeveloped or underdeveloped destination to pay a lower price, the natural hazard risks must be carefully considered in terms of facility quality and policies and procedures implemented and followed in the face of a natural hazard situation where the patients (and their companion travelers) must be evacuated to “someplace else” or “shelter in place”. 

But what if the natural hazard event happens immediately prior to arrival at the destination while in transit? Will the hospital or clinic or hotel/resort be open to welcome them as scheduled? What is Plan B?

How will you be alerted to a problem if one arises for a patient in transit? At SurgeryShopper.com all flights to all treatment destinations are monitored. Self-driving patients are also in frequent contact and routes monitored along their journey until they have arrived and checked in and are known to be reasonably safe and secure. What’s your safety and patient security plan and standard?

What is your professional duty of care as a facilitator?

To accurately assess the seismic performance of a building requires considerable engineering expertise. That’s not the level for duty of care that will be expected of you. But what is reasonable? That is your first consideration in drafting your unique checklist for your business to be used as a differentiating tool that represents a component of your quality management plan and standards for your company. 

For my company, SurgerShopper.com, we believe that it is our duty to inspect the premises and inquire about seismic safety, and request permission to review the latest engineering statement that certifies recency, adequacy, and seismic considerations about their construction and their seismic incident management plan(s).

But we also prefer to have “a standard” that applies to all approved network facilities, regardless of which country or locality they are situated.  So since our network consists of healthcare facilities in the USA, we’ve elected to adopt the FEMA guidance to benchmark for our standards. That creates a problem because when we compare to other localities, most other medical tourism destination facilities and hotels tend to fail to  measure up in this criteria. And if there are different standards for building safety and construction, or you default to the average “local standard” of quality, safety and construction, you no longer have a “standard” but instead, a variable.

 

Let me share a little history with you:

In the 1989 Loma Prieta, California earthquake, newer hospital buildings generally performed well. Even though many suffered minor system and architectural finish damage and temporary elevator stoppage, there were no operational interruptions. The state licensed acute care hospitals constructed under the provisions of the Hospital Act suffered virtually no damage whereas some pre-Hospital Act facilities suffered some structural damage. 

  • The Veterans Administration Hospital was a campus of some SO buildings
    containing 420 general hospital beds. Many of the buildings were construct
    ed between the 1920s and 1940s and the most recently occupied building
    was built in 1949. Forty-seven persons were killed in the collapse of two
    buildings that had been constructed in 1925. Subsequent to the earthquake,
    the site was abandoned (it is now a public park). A replacement hospital built at a
    cost of approximately $54 million did not open until 1977. 
  • Olive View Hospital was a then new county facility with over 600 beds valued at
    $25 million. The building suffered severe structural damage, two patients died as a
    result of failure of life support equipment, and one staff member was killed
    by the collapse of a landscaped plaza structure. After the earthquake, the building was demolished and a new building constructed on the same site. This facility did not open until 14 years after the earthquake, and its cost was approximately $150 million.
Both were commissioned, legally open, and most likely accredited facilities. Will you simply tic and box on a site inspection form and abdicate all responsibility and then ask the patient/client to sign a disclaimer form? If something bad happens, do you truly believe that if pursued legally that your defense of your policy and procedure is going to work? It’s your company, your reputation and brand integrity – and other people’s lives entrusted to your service. If you get paid a fee and hold yourself out to be professional – abdication cannot be acceptable to you.

If your network facilities are near a known seismically active area or not, are you willing to risk saying “I don’t know, I didn’t check or think to ask” in the witness stand as you are grilled about your quality and safety standards?
 
What about JCI accreditation and all the other accreditation standards?

 

They don’t true up to my standards in the USA, nor do they need to. The international accreditation standards don’t apply “American” standards as the measurement criteria. Instead they benchmark against the average local standard of the community in which the care is delivered. 

Nevertheless, since seismic safety is a complex issue that involves a relatively uncommon hazard and community values as well as life safety, this knowledge is not always applied even in areas of high risk.

In California, for example, earthquakes have been a constant concern for many years and seismic building codes, although initially inadequate by today’s standards, have been in effect for over 50 years. In other parts of the country, however, where the last major earthquake was well before anyone’s memory, this is not so and even a moderate earthquake may do devastating damage. 

So if SurgeryShopper.com applies its own standards, equally and without prejudice within the USA, the national guidance comes from assimilating various bodies of guidance from The National Fire Protection Association (NFPA), NFPA 101 (“the Life Safety Code”), The Federal Emergency Management Agency (FEMA), the International Building Code (IBC) which is also accepted for use in Abu Dhabi, the Caribbean Community, Colombia, Georgia, Honduras, Afghanistan and Saudi Arabia and other relevant reference standards. The code provisions are intended to protect public health and safety while avoiding both unnecessary costs and preferential treatment of specific materials or methods of construction. But one cannot simply “assume” without verification that these standards were incorporated into building standards that were in effect when the hospital, clinic, or accommodation were constructed, or what’s changed since. So, we read, assess, decide, and rely upon statements of compliance or non-compliance from competent engineers – but we don’t simply “assume” facts not in evidence. 

As for me, none of the accreditation standards in use or even approved by ISQua, (now called The International Society for Quality in Health Care External Evaluation Association (IEEA), are adequate for me. Why? Because in some cases, as in the case of TEMOS, since they won’t permit me to even review their standards without paying a fee of several thousands of dollars, I elected to not even accept any of them as a basis of quality in this matter. 

I prefer our standards be unique to our brand, and brand agnostic to the accreditation and other programs that award designations, accreditations and certifications. I don’t go by what plaques they have on the wall, I go by deeper inspection and assessment at an operational level versus a checklist level of if they are accredited or certified, or not. My checklist is different and unique to SurgeryShopper.com. At what level will your checklist be established?

Again, the international accrediting bodies all survey to assure that the facility meets the average local standard of the community in which the care is rendered. I don’t want to settle for the average local standard of the community where they are situated. If their standards meet my criteria for SurgeryShopper.com good for them. If not, it doesn’t matter. It is my set of standards that is the basis of whether a provider facility, clinic, spa or resort is admitted to our exclusive network. 

Which bodies of knowledge and guidance will you study, to what extent, and how will you formulate your internal standards? That depends on your anticipated use cases. It is not something that one can provide for you to cut and paste. After all, are you medical or dental or wellness tourism “imitator” or an “independent leader” who creates a pathway where none previously existed? Your brand value and integrity and storytelling messages depend on your critically determined answer to this question.

  • Those responsible for inspecting a health care facility also should consider additional seismic performance requirements to protect the occupants and contents of their building.  When interviewing hospital executives, ask about which requirements have been the subject of managerial solutions through emergency planning procedures have been implemented. Although the basic strategy for reducing damage to a healthcare facility involves design in accordance with up-to-date and appropriate seismic requirements like the NEHRP Recommended Provisions, it also involves an understanding by the hospital, clinic or ASC leadership. 

Here are some basics to consider as model seismic performance goals for health care facilities:

  1. Patients, staff (medical, nursing, technical, and support personnel), and visitors within and outside the facility must be protected during an earthquake and must be able to evacuate the facility quickly and safely after an earthquake.
  2. Emergency systems in the facility must remain operational after an earthquake.
  3. Rescue and emergency workers must be able to enter the facility immediately after an earthquake, encountering minimum interference and danger.
  4. The property damage to the facility must be only what can be tolerated after a destructive earthquake.
  5. The facility must remain functional for any planned disaster response role.
  6. The complexity of the building form and structural framing system-It is much more economical to provide seismic resistance in a building with a simple form and framing.   Were current seismic resistance safety standards addressed after or during initial construction? In other words, the cost of seismic remediation and retrofit can rise quickly if no attention is given to it until after the configuration of the building, the structural framing plan, and the materials of construction have been selected. How old is the building in question? 

In Greece, for instance, I found many older hospitals and clinics built decades ago that would never pass international hospital accreditation because the cost to improve or modify physical plant to bring them up to current standards that I use for my assessments which incorporates many of the standard more popular, well established and accepted accreditation standards were reviewed to build my standards. Yes, dialysis and other services may be less expensive there, but the tradeoff is that in many cases, buildings are older. Some hospitals are a patchwork quilt of cobbled together buildings joined by a makeshift corridor as an add on.  As a former hospital executive, I know and understand where the lines are drawn to defend a business case for physical improvement and remodeling to achieve accreditation by JCI or its IEEA approved rival accreditation scheme. It isn’t going to happen – not in Greece. No matter how much advertising or branding or other marketing they do for medical tourism business attractiveness. In Turkey I saw similar, and in India and Ukraine and Argentina, and Philippines, and in Mexico, and in Thailand, and even in the USA.  But if you elect to conduct business by merely exchanging emails to negotiate a representation agreement or facilitator referral agreement, and subject clients/patients to this standard of operation and vetting, I believe you should be hung from the public square and ridiculed publicly, and stripped of all corporate veils and prosecuted as a public nuisance.

For the purpose of this education and training article, health care facilities can include:

  • Urban Medical Centers-Dense groupings of predominantly large buildings built over a considerable period of time with different phases of construction. Buildings are often adjacent to one another or directly connected; small ancillary buildings often form part of the complex. Such centers provide a wide range of services, including teaching. 
  • Large General Hospitals-Mid- to high-rise structures with connected or adjacent support facilities. They provide a wide range of services including acute care and specialized diagnostic or treatment capability. 
  • Community Hospitals-Low-rise structures offering a wide range of services.
  • Special Hospitals-Generally low- or mid-rise structures, residential in nature, that focus on a particular medical specialty, such as cancer or drug addiction, or a particular population, such as children.
  • Convalescent Homes-Similar to large houses, multifamily housing, or hotels/motels and residential in nature. They focus on the elderly and provide long-term care and limited medical services. This can also be used to describe certain hotels and health recuperation resorts that may cater to medical and dental visitors. 
  • Other kinds of facilities deal with minor surgery such as physician or dental clinics, or ASCs that perform surgery on an outpatient basis or provide for long-term residential health care and rehabilitation needs. 

Each of these building types presents different earthquake-related problems because of its construction and occupancy.

The basic design problems affecting the seismic performance of healthcare
facilities are:
• Building form irregularities in both the horizontal and vertical planes;
• Discontinuities in strength between the major structural elements of the building;
• Inadequate diaphragms;
• Effects of nonstructural elements on the structural system;
• Deficiencies in the connections that tie the elements of the building together; and
• Damage to the nonstructural components (including utility systems) and contents of the building.

As a former firefighter and trained fire inspector, I always seem to take notice of potential egress complications and the disruption of post-earthquake or other natural hazard operations. I believe that’s part of the situational awareness training that was drilled into me. It influences which chair and direction I will select in a restaurant, public hall, theater, and other places, how and where I walk in a location where I am unfamiliar, and how I walk a hospital or hotel.  You may not have the benefit of equal training, experience and work history.  I don’t mind sharing what I know to our mutual benefit and our clients’ benefits as well.

But be informed that while a simple and symmetrical building form allows for the most even and balanced distribution of forces, symmetry of form will not ensure low torsional effects.

For instance, even in simple symmetrical rectangular buildings the location of stiff stair and  elevator cores, solid and glazed walls, or other design elements that add mass to only one part of the building can result in different
locations of the center of mass and the center of rigidity, and the torsion or twisting that results during an earthquake has frequently caused substantial damage.

But you can imagine that knowing this and coming upon the Ruvo Center owned by Cleveland Clinic, but located in Las Vegas, gave me pause. Sorry Mr Gehry. I love your creativity, but can you tell me about the seismic safety built in? But the buildings (and hotels) need not be outlandish to make you begin to compare.

Lou Ruvo Center for Brain Health, Las Vegas, NV USA

Check out the amazing array of hospitals and hospital designs around the world to compare to what you have already encountered on any fam tours to medical tourism destinations, worldwide. Then for a professional development exercise, for each one, start listing the questions you want to ask from what you’ve just studied above, what you already know and start building your checklist with the questions, and your best objective answers to create your unique standards sets.

Re-entrant corners

A common building form that presents seismic design problems is that of the “re-entrant corner.” The re-entrant corner is the common characteristic of overall building configurations that, in plan, assume the shape of an L, T, U, H, +, ⬜ or a combination of these shapes. These building shapes permit large plan areas to be accommodated in relatively compact form while still providing a high percentage of perimeter rooms with access to air and light. Where I recently encountered this was in Dubai Healthcare City while touring several health facilities in UAE.

Because of these characteristics, they are commonly used in healthcare facility design. These configurations are so common and familiar that the fact that they represent one of the most difficult problem areas in seismic design may seem surprising, but examples of earthquake damage to re-entrant corner type buildings are common.

Typical problems with the building forms commonly used for health care facilities include:

  • The use of internal courtyards, which can cause torsional effects at the interior corners of the building.  For example, Pablo Tobón Uribe Hospital in Medellin and IJN Heart Hospital in Kuala Lumpur, both have this issue, as do many others in the USA and other countries. Have you inspected these facilities? Did you take notice or did you not know what you didn’t know? Did the tour director showing you around even mention seismic safety standards of the hospital? Did anyone ask?
  • The use of narrow wings, which can cause torsional effects and stress concentrations at the re-entrant corners (This was what I noticed immediately in the facilities I toured in Dubai Healthcare City. The vertical building designs and the many clinics and diagnostic center corridors may have been to code but they felt (and measured) more narrow that I would allow in my network facilities.) 
  • The placement of tall nursing floor structures above a broad base of diagnostic and treatment areas, which can result in problems associated with vertical setbacks.  I’ve seen this issue in many modern hospitals, across 117 countries.
  • Soft first levels – Large discontinuities or abrupt changes in the building strength or stiffness of a building can cause adverse seismic response effects. For example, throughout Japan, many modern buildings are designed with parking garages as the first story – which are “soft” first levels. Soft stories at any level create problems, but a stiffness discontinuity between the first and second floors tend to result in the most serious conditions because forces are generally greatest near the base of the building and swings and sways (momentum) occur closer to the top. Discontinuity also may occur when some vertical framing elements are not brought down to the foundation but are stopped at the second floor to increase the openness at ground level. This condition creates a discontinuous load path resulting in an abrupt change of strength and stiffness at the point of change.  Finally, the “soft” story may be created by an open floor that supports heavy structural or nonstructural walls above. This situation is most serious when the wall above is a shear wall acting as a major lateral force resisting element.

These four design considerations are so programmed into my assessment criteria from my training in fireground tactics and assessment, that when I walk up to the building before I even enter, I’ve already formed an initial impression. The rest of my time is spent on confirming my initial impressions or proving I was wrong.

The complexity of health care facilities tends to result in vertical structural discontinuities. Among the more common situations are the following:

  • The interconnection of tall, long-span, flexible spaces (treatment and diagnostic areas) with low, short-span, rigid areas featuring shear walls (patient rooms and hallways).
  • The placement of stiff floors above a more flexible first floor.
  • Discontinuities in column or shear wall placement from one floor to another.
Drift Displacements
Drift is the lateral displacement of one floor relative to the floor below. In earthquake prone places, buildings need drift control to restrict damage to interior partitions and stair enclosures (thinking egress in an emergency when lifts are automatically programmed to head to the bottom floor and shut down and all signage reads “use stairs in event of emergency!” ), use of glass for walls, and envelope cladding systems, and to momize differential movement demands on the seismic resisting structural elements.
 
You could spend hundreds of hours to study all this before writing your criteria and standards and creating your checklist. Instead, get familiar with the issues so that you can more easily appreciate risks when you make your direct observations and assessments for due diligence.
 
Nonstructural considerations
Severe earthquake damage can occur even if the building structure remains essentially intact.
 

Your thought processes could start as follows:

  • If the damage to the building is minimal but their x-ray department or surgical suites are compromised, and your patient has traveled a long distance to arrive and find that the damage renders the hospital or clinic out of service, how will you respond? What is plan B?
The nonstructural components with both life safety and major property damage consequences include exterior nonbearing walls, exterior veneers, infill walls, interior partition systems, windows, ceiling systems, elevators, mechanical equipment, and electrical and lighting equipment. 

All these components are subject to damage, either directly due to shaking or because of movement of the structure (which may be an intentional part of the seismic design). 

Health care facility occupants are particularly vulnerable to nonstructural damage. While school children and office workers may duck under desks and be safe from falling objects like light fixtures or glass, the patient in a bed or wheelchair has no such option. Ceiling tile and wall finishes that fall on hallways and stairs can make movement difficult, particularly if combined with power failure and loss of lights. How about we walk you through a hospital blindfolded and see how you do or confined to bed or a wheelchair and start simulating things falling from walls as you sit or lie there helpless and vulnerable?
Would that change your perspectives?
But wait, there’s more:
  • In assessing the impact of possible damage, secondary effects from equipment damage must be considered. Fires and explosions resulting from damaged mechanical and electrical equipment, broken laboratory equipment, and spilled chemicals represent secondary effects of earthquakes that also are a considerable hazard to life and property.
  • Large capacity hot water boilers, other pressure vessels such as autoclaves that sterilize medical implements and broken distillation pipes can release fluids at hazardous temperatures.
  • Large hot water boilers that operate at over 212°F (100° C) pose a very serious hazard since the sudden decrease in pressure caused by a rupture of the vessel can result in instantaneous conversion of superheated hot water to steam, and the remainder of the vessel can disintegrate explosively showering the area with hot material and igniting combustible material.
  • Free-standing kitchen equipment on patient floors designated as “nourishment stations” and electrical equipment such as transformers, switchboards, emergency generators, and lighting fixtures can fall, causing injuries as well as fires.
  • Heating equipment located on roofs or hung in open spaces or service areas typically is not designed for lateral forces. These pieces of equipment can easily fall and cause considerable damage or injury.
  • Mechanical system grills and diffusers also can fall from ceilings. Even such nonstructural components as glazing systems can create additional hazards. Although damage patterns for glazing systems have not been well researched, glass breakage is related to support conditions, the temper of the glass and its thickness and size, and the type and direction of loading.
  • Large windows usually break at somewhat lower loads than smaller windows since large windows behave like a membrane or diaphragm. With sufficient space for movement within the frame, a frame that does not rack, low glass loading, and reasonably careful design and placement, good performance can be expected.  Glass joint treatment also is a factor in the overall performance of a curtain wall or window unit system; if the edges are restrained, failure is likely. In this context, it also should be remembered that the sealants and gasket materials providing flexibility can lose their resiliency with age and exposure and therefore may require periodic replacement.
  • Much of the contents of a healthcare facility is essential to its diagnostic and treatment function. In hospitals without electronic medical records, the overturning of an office file cabinet may be a temporary nuisance for a commercial company, but the overturning of a patient records cabinet can be a critical problem in a hospital since these records are an essential aspect of treatment. Many other supplies such as medications or instrument packs are essential for emergency treatment that may be necessary immediately after an earthquake.
  • Several things can happen to stairwells during an earthquake. First, stairs tend to act as diagonal bracing between floors and interstory drift can induce damaging loads and racking that may result in collapse or failure if the stair framing is anchored to the structural system without sliding joints at the end. Second, masonry or concrete fire walls surrounding stairs can fracture leaving egress pathways strewn with debris. Staircase towers can collapse independently of the building they were expected to serve.
  • Experience indicates that doors and frames often jam in earthquakes and cannot be opened. Heavy fire doors leading to egress routes are especially vulnerable because fire safety regulations require a heavy and tight assembly that becomes immovable when the door frame is distorted by earthquake motion. The health care facility with its numerous small rooms opening to public corridors is especially vulnerable in this respect. Safe, direct, unobstructed exit routes are necessary so that occupants can safely exit the building.
  • Ceiling systems, lighting systems, ventilation systems, and windows that enclose these egress routes must be designed as critical components and located in such a way that their failure will not impede egress. Most national and regional fire codes require hospital egress routes to have emergency lighting and signage; however, the anchorage of these elements in both the horizontal and vertical direction must be considered in their design. Canopies and porches at the entrances to the facility are especially vulnerable if not designed for lateral loads. Their collapse may cause injuries among exiting occupants and they can become a major impediment to emergency procedures.  So I assumed that on one of my consultations in Nigeria. I asked for copies of the fire codes for the jurisdiction in which we were consulting to help them build a medical tourism hospital. Imagine my disappointment when they could not be produced for hospital or hotel because they had yet to be codified! Be prepared for this in places that are remote and undeveloped or underdeveloped, but that offer great prices for medical tourism services!
  • Oh, and is there a heliport on the roof as there is at Florence Nightingale Hospital in Istanbul? Neat! But what about a possible earthquake occurring in the body of water around the corner? How will the building be affected. Did you ask?
And there you sit in the wheelchair or the bed with the emergency exit signage in Hangul – the alphabetic system used in Yonsei Severance Hospital in Korea, a JCI accredited teaching hospital with many physical structures cobbled together in the standard  L, T, U, H, +, ⬜ or a combination of those shapes giving rise to the re-entrant corners you’ve just read about. Now do you understand my dismissal of simply “having” JCI accreditation? Hangul is the average level of care, safety, quality in the community in which the care is being rendered. I don’t read Hangul, do you? Does your patient? There is no language requirement for a JCI hospital or one accredited by some other IEEA-approved accreditation scheme to speak or render care in the language of your medical or dental travel patient! More issues to consider for your checklist The ten seismic design issues that must be considered are:
  1. The anticipated level of earthquake ground motion for which the health care facility will be designed;
  2. The possible impacts of site geology on the performance of the building;
  3. The impact of the building occupancy on the seismic design of the building; 
  4. The selection of the configuration of the building and its effect on seismic performance;
  5. The selection and design of the structural system of the facility and its expected performance;
  6. The selection and application of building materials in the design and their expected performance;
  7. The detailing of the structural connections;
  8. The design and protection of the critical functions of the facility;
  9. The design and protection of the nonstructural components and equipment; and 
  10. The assurance of good construction quality.
Building code occupancy classifications historically have been based on the potential hazards associated with fire. Because of the characteristics of the earthquake problem, a specific occupancy classification is necessary. The approach in the NEHRP Recommended Provisions defines occupancy exposure to seismic hazards based on, but not limited to, the following:
  1. The typical number, age, and condition of the occupants within the building type and its immediate environs;
  2. The typical size, height, and area of the building type;
  3. The spacing of the building type in relation to public rights-of-way; and
  4. The degree of built-in or brought-in hazards based on the typical use of the building type.
To write your own brand standards, read what’s available in the different resources and authoritative guides I’ve mentioned above. As you do this, for a useful practical exercise start writing down what you’d look for (for direct observation) now that you are aware of certain issues and risks, and what questions you would ask and to whom you would ask them.  
 
Next to each question, write out what the “right answer” is for your unique standard or criteria. It takes time. It doesn’t take a lot of money. In the beginning of your health tourism business you won’t have a lot of clients taking your time, so you should be able to bootstrap your seismic checklist development. You’ll continually improve it as part of your risk-based thinking and continuous quality improvement activities. Right?
The more common nonstructural elements in healthcare facilities and partner accommodation outlets that should be given special design attention include:
Appendages  – Entrance canopies, overhangs, balconies/roof-mounted mechanical units and signs/roofed walkways
Enclosures – Exterior nonbearing walls/exterior infill walls/veneer attachments/curtain wall system attachments
Partitions – Stairs and shafts/horizontal exits/corridors/fire separation partitions
Ceilings – Fire-rated and non-fire-rated
Doors/Windows – Room-to-hallway doors/fire doors/lobby doors and glazing/windows and curtain walls/atrium spaces and skylights/glass elevator enclosures
Lighting – Light fixtures/emergency lighting
Emergency – Structural fireproofing/emergency electrical system/fire and smoke detection system/fire suppression systems (sprinkler)/smoke removal systems/signage Mechanical – Large equipment including chillers, heat pumps, boilers, furnaces, fans/smaller equipment including room air conditioning or heating units/cooling towers/tanks, heat exchangers, and pressure vessels/utility and service interfaces/ducts and diffusers/piping distribution systems  Electrical – Communications systems/electrical bus ducts and primary cable systems/electric motor control centers, transformers, and switchgear; and  Contents – Diagnostic and treatment room equipment /radiology and operating room equipment /laboratory equipment and supplies/patient records storage/nursing ward storage and supplies/computers, printers, and copying equipment/filing cabinets and bookcases/food preparation equipment.
Keep in mind that your checklist may change and criteria may change depending on the type of health facility being assessed. 
GLOSSARY OF TERMS

Use this glossary of terms to help you understand the terms used by engineers and architects that you may read or hear quoted when you ask questions.

ACCELERATION The rate of increase in ground velocity as seismic waves travel through the earth. The ground moves backward and forward; acceleration is related to velocity and displacement.

ACCEPTABLE RISK The probability of social or economic consequences due to earthquakes that is low enough (for example, in comparison with other natural or man-made risks) to be judged by appropriate authorities to represent a realistic basis for determining design requirements for engineered structures or for taking certain social or economic actions.

AMPLITUDE The extent of a vibratory movement.

ARCHITECTURAL SYSTEMS Systems such as lighting, cladding, ceilings, partitions, envelope systems, and finishes.

COMPONENT Part of an architectural, electrical, mechanical, or structural system.

CONNECTION A point at which different structural members are joined to each other or to the ground.

DAMAGE Any economic loss or destruction caused by earthquakes.

DEFLECTION The state of being turned aside from a straight line. See drift.

DESIGN EARTHQUAKE In the NEHRP Recommended Provisions, the earthquake that produces ground motions at the site under consideration that have a 90 percent probability of not being exceeded in 50 years.

DESIGN EVENT, DESIGN SEISMIC EVENT A specification of one or more earthquake source parameters and of the location of energy release with respect to the site of interest; used for earthquake-resistant design of a structure.

DIAPHRAGM A horizontal or nearly horizontal structural element designed to transmit lateral or seismic forces to the vertical elements of the seismic resisting system.

DRIFT Lateral deflection of a building caused by lateral forces.

DUCTILITY Capability to be drawn out without breaking or fracture. Flexibility is a very close synonym.

EARTHQUAKE A sudden motion or vibration in the earth caused by the abrupt release of energy in the earth’s lithosphere. The wave motion may range from violent at some locations to imperceptible at others.

EFFECTIVE PEAK ACCELERATION and EFFECTIVE PEAK VELOCITY-RELATED ACCELERATION Coefficients for determining the prescribed seismic forces shown on maps in the NEHRP Recommended Provisions.

ELASTIC Capable of recovering size and shape after deformation.

ELEMENTS AT RISK Population, properties, and economic activities (including public services, etc.) at risk in a given area.

EXCEEDENCE PROBABILITY The probability that a specified level of ground motion or specified social or economic consequences of earthquakes will be exceeded at the site or in a region during a specified exposure time.

EXPOSURE The potential economic loss to all or certain subsets of structures as a result of one or more earthquakes in an area. This term usually refers to the insured value of structures carried by one of more insurers.

FAULT A fracture in the earth’s crust accompanied by a displacement of one side of the fracture with respect to the other and in a direction parallel to the fracture.

FRAME, BRACED An essentially vertical truss or its equivalent of the concentric or eccentric type that is provided in a building frame or dual system to resist seismic forces.

FRAME, INTERMEDIATE MOMENT A space frame in which members and joints are capable of resisting forces by flexure as well as along the axis of the members.

FRAME, ORDINARY MOMENT A space frame in which members and joints are capable of resisting forces by flexure as well as along the axis of the members.

FRAME, SPACE A structural system composed of interconnected members, other than bearing walls, that is capable of supporting vertical loads and that also may provide resistance to seismic forces.

FRAME, SPECIAL MOMENT A space frame in which members and joints are capable of resisting forces by flexure as well as along the axis of the members.

FRAME SYSTEM, BUILDING A structural system with an essentially complete space frame providing support for vertical loads. Seismic force resistance is provided by shear walls or braced frames.

FRAME SYSTEM, DUAL A structural system with an essentially complete space frame providing support for vertical loads. A moment resisting frame that is capable of resisting at least 25 percent of the prescribed seismic forces should be provided. The total seismic force resistance is provided by the combination of the moment resisting frame and the shear walls or braced frames in proportion to their relative rigidities.

FRAME SYSTEM, MOMENT RESISTING A structural system with an essentially complete space frame providing support for vertical loads. Seismic force resistance is provided by special, intermediate, or ordinary moment frames capable of resisting the total prescribed seismic forces.

INTENSITY The apparent effect that an earthquake produces at a given location. In the United States, intensity is frequently measured by the Modified Mercalli Index (MMI). The intensity scale most frequently used in Europe is the Rossi-Forell scale. A modification of the Mercalli is used in many former Soviet Union states. See the following section of this Glossary, “Measures of Earthquake Magnitude and Intensity.”

JOINT A point at which plural parts of one structural member are joined to each other into one member.

LIQUEFACTION The conversion of a solid into a liquid by heat, pressure, or violent motion.

LOAD, DEAD The gravity load created by the weight of all permanent structural and nonstructural building components such as walls, floors, roofs, and the operating weight of fixed service equipment.

LOAD, LIVE Moving or movable external loading on a structure. It includes the weight of people, furnishings, equipment, and other things not related to the structure. It does not include wind load, earthquake load, or dead load.

LOSS Any adverse economic or social consequences caused by earthquakes.

MASS A quantity or aggregate of matter. It is the property of a body that is a measure of its inertia taken as a measure of the amount of material it contains that causes a body to have weight.

MERCALLI SCALE Named after Giuseppe Mercalli, an Italian priest and geologist, it is an arbitrary scale of earthquake intensity related to damage produced. See the following section of this Glossary, “Measures of Earthquake Magnitude and Intensity.”

PERIOD The elapsed time of a single cycle of a vibratory motion or oscillation.

RESONANCE The amplification of a vibratory movement occurring when the rhythm of an impulse or periodic stimulus coincides with the rhythm of the oscillation (period). For example, when a child on a swing is pushed with the natural frequency of a swing.

RICHTER SCALE Named after its creator, the American seismologist Charles R. Richter, a logarithmic scale expressing the magnitude of a seismic (earthquake) disturbance in terms of its dissipated energy. See the following section of this Glossary, “Measures of Earthquake Magnitude and Intensity.” 

SEISMIC Of, subject to, or caused by an earthquake or an earth vibration.

SEISMIC EVENT The abrupt release of energy in the earth’s lithosphere causing an earthquake.

SEISMIC FORCES The assumed forces prescribed in the NEHRP Recommended Provisions related to the response of the building to earthquake motions to be used in the design of a building and its components.

SEISMIC HAZARD Any physical phenomenon such as ground shaking or ground failure associated with an earthquake that may produce adverse effects on human activities.  For example, in Southern Utah and areas nearby, we get ground shakes that come from rockslides and from drills and testing at the Nevada Test Site where they routinely carry our practice missions by Air Force and other defense agencies using explosive devices. We also experience earthquakes. At higher, snow elevations, they may also get shakes from avalanches that occur.

SEISMIC HAZARD EXPOSURE GROUP A classification assigned in the NEHRP Recommended Provisions to a building based on its use. 

SEISMIC PERFORMANCE CATEGORY A classification assigned to a building as defined in the NEHRP Recommended Provisions.

SEISMIC RESISTING SYSTEM The part of the structural system that has been considered in the design to provide the required resistance to the prescribed seismic forces.

SEISMIC RISK The probability that social or economic consequences of an earthquake will equal or exceed specified values at a site, at several sites, or in an area during a specified exposure time.

SEISMIC ZONES Earth surface areas defined by earthquake occurrences of relatively uniform frequency, intensity, and magnitude. Such zones are defined by both global divisions and national subdivisions. They are generally large areas within which seismic design requirements for structures are constant.

SHEAR A deformation in which parallel planes slide relative to each other and remain parallel.

SHEAR PANEL A floor, roof, or wall component sheathed to act as a shear wall or diaphragm.

STIFFNESS Resistance to deformation of a structural element or system.

STRENGTH The capability of a material or structural member to resist or withstand applied forces.

TORQUE The action or force that tends to produce rotation. In a sense, it is the product of a force and a lever arm as in the action of a wrench twisting a bolt.

TORSION The twisting of a structural member about its longitudinal axis. It is frequently generated by two equal and opposite torques, one at each end.

VALUE AT RISK The potential economic loss (whether insured or not) to all or certain subsets of structures as a result of one or more earthquakes in an area.

VELOCITY The rate of motion. In earthquakes, it is usually calculated in inches per second or centimeters per second. 

VULNERABILITY The degree of loss to a given element at risk, or set of such elements, resulting from an earthquake of a given magnitude or intensity, which is usually expressed on a scale of from 0 (no damage) to 10 (total loss).

WALL, BEARING A wall providing support for vertical loads; it may be exterior or interior.

WALL, NONBEARING A wall that does not provide support for vertical loads other than its own weight as permitted by the building code. It may be exterior or interior.

WALL, SHEAR A wall, bearing or nonbearing, designed to resist seismic forces acting in the plane of the wall.

WALL SYSTEM, BEARING A structural system with bearing walls providing support for all or major portions of the vertical loads. Seismic force resistance is provided by shear walls or braced frames.

WAVES A ground motion best described as vibration that is created or generated by a fault rupture. Earthquakes consist of a rapid succession of three wave types: the “P” or primary wave followed by both the “S” or secondary wave and a surface wave.

The following excerpt from Bruce A. Bolt’s 1978 book, Earthquake: A Primer, (W. H. Freeman and Company, San Francisco, California), describes modified Mercalli intensity values (1956 version):

I. Not felt. Marginal and long period effects of large earth
quakes.

II. Felt by persons at rest, on upper floors, or favorably placed.

III. Felt indoors. Hanging objects swing. Vibration like passing
of light trucks. Duration estimated. May not be recognized
as an earthquake.

IV. Hanging objects swing. Vibration like passing of heavy
trucks or sensation of a jolt like a heavy ball striking the
walls. Standing cars rock. Windows, dishes, doors rattle.
Glasses clink. Crockery clashes. In the upper range of IV,
wooden walls and frames creak.

V. Felt outdoors; direction estimated. Sleepers wakened.
Liquids disturbed, some spilled. Small unstable objects displaced or upset. Doors swing, close, open. Shutters, pictures move. Pendulum clocks stop, start, change rate.

VI. Felt by all. Many frightened and run outdoors. Persons walk unsteadily. Windows, dishes, glassware broken. Knickknacks, books, etc., off shelves. Pictures off walls. Furniture overturned. Weak plaster, Masonry D cracked. Small bells ring (church and school). Trees, bushes shaken visibly or heard to rustle. 

VII. Difficult to stand. Noticed by drivers. Hanging objects quiver. Furniture broken. Damage to Masonry D, including cracks. Weak chimneys broken at roof line. Fall of plaster, loose bricks, stones, tiles, cornices, also unbraced
parapets and architectural ornaments. Some cracks in
Masonry C. Waves on ponds, water turbid with mud. Small slides and caving in along sand or gravel banks. Large bells ring. Concrete irrigation ditches damaged.

VIII. Steering of cars affected. Damage to Masonry C; partial collapse. Some damage to Masonry B; none to Masonry A. Fall of stucco and some masonry walls. Twisting, fall of chimneys, factory stacks, monuments, towers, elevated tanks. Frame houses moved on foundations if not bolted down; loose panel walls thrown out. Decayed piling broken off. Branches broken from trees. Changes in flow or temperature of springs and wells. Cracks in wet ground and on steep slopes.

IX. General panic. Masonry D destroyed; Masonry C heavily damaged, sometimes with complete collapse; Masonry B seriously damaged. General damage to foundations. Frame structures, if not bolted down, shifted off foundations. Frames racked. Serious damage to reservoirs. Underground pipes broken. Conspicuous cracks in the ground. In alluviated areas, sand and mud ejected, earthquake fountains and sand craters.

X. Most masonry and frame structures destroyed with their foundations. Some well-built wooden structures and bridges destroyed. Serious damage to dams, dikes, embankments. Large landslides. Water thrown on banks of canals, rivers, lakes, etc. Sand and mud shifted horizontally on beaches and flat land. Rails bent slightly.

XI. Rails bent greatly. Underground pipelines completely out of service.

XII. Damage nearly total. Large rock masses displaced. Lines of sight and level distorted. Objects thrown in the air.

Masonry definitions, from C. F. Richter’s 1958 book, Elementary Seismology  (W. H. Freeman and Company, San Francisco, California), are as follows: 

Masonry A-good workmanship, mortar, and design; reinforced, especially laterally; bound together by using steel, concrete, etc.; designed to resist lateral
forces. 

Masonry B-Good workmanship and mortar; reinforced but not designed in detail to resist lateral forces. 

Masonry C-Ordinary workmanship and mortar; no extreme weaknesses like failing to tie in at corners but not
reinforced or designed against horizontal forces. 

Masonry D-Weak materials such as adobe, poor mortar, low standards of workmanship; weak horizontally. 

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In closing, this reading and the recommended activities is not intended to be exhaustive. Instead it is shared with the intention to create awareness and support your efforts for risk-based thinking as you plan, prepare and launch your new medical tourism business.

Your quality policies, procedures, standards and criteria will be unique to your brand. How far you go, how deeply you develop this, and how you use it in daily practice is up to you. There is no right or wrong. Just do your best to protect your clients and keep them safe as is reasonably possible under your care and control. 

If I can be of assistance to help you build your standards, policies, procedures and criteria, I am available to consult on a retained basis or an ad hoc assignment to review what you’ve developed and add critical guidance. Call me at +1 (800) 727.4160 to discuss your business development requirements.