This study aimed to determine the domains and indicators for assessing HDR through a systematic review. There is a very critical and crucial deference between the concept of risk reduction (safety and preparedness) and resilience. Safety is defined as “the state in which the risk of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management (53). While resilience defines as a concept for the ability or capacity of a system or community to deal with risk (54). Based on these definitions, we see that the approach of safety and risk reduction is mainly to reduce the level of risk, but the approach of resilience is to continue the function of a system while the system is facing risk.
It is important to evaluate and monitor the resilience of hospitals as a system to withstand the impacts of disasters and to continue to function properly and timely. Therefore, the comprehensive assessment of HDR helps to find the weaknesses and challenges in the scope of disaster risk and removing them to mitigate the harmful consequences of disasters (52). In fact, this assessment produced sufficient evidence to influence considerably the engineering structural and non-structural outcomes of the hospitals affected by a disaster.
The desirable performance of hospitals during and after disasters and their continuity to services depends on many factors such as hospital building stability including the structural and non-structural systems (55). Several studies were carried out in different fields of HDR such as organizational resilience that related to functional services of the hospital (1, 35, 56-58) but the studies that especially related to structural and non-structural systems of hospitals were scant. Thus, a systematic method of HDR about the structural and non-structural systems would be required.
To achieve this aim, the included articles concentrated on the importance of hospital resilience by surveying the building and utility situation in disasters, but most of them focused more on electrical and water utilities and transportation networks in hospitals (28, 30, 35, 42, 44, 46, 48, 50, 59). It showed that other utilities in hospitals like communication system, gas supply system, sewage system and also non-structural components of buildings such as architectural elements have been less considered. In the case of healthcare facilities, nonstructural components often represented greater economic value rather than the structure itself. Analyses indicated that nonstructural components generally accounted for more than 80% of the total costs of a hospital (60).
The model, tools and framework in table 1 have some properties that help to improve the proposed model for assessing HDR. The HSI tool and frameworks proposed by Zhong had an all-hazard approach. The HSI tool had a comprehensive view on the performance of all the utility services and the structural systems in a qualitative and self-assessment approach. This assessment tool has three sections including structural, non-structural and disaster management system (30). The structural system refers to elements of building that bear loads. Other elements of buildings such as utilities and architectural systems are categorized as non-structural system. One of the disadvantages of this tool is that the non-structural section is very wide and consisted of many sub-categories. The disaster management category is emphasized by preparedness of the hospital system including staff readiness and preparing action plans in HSI. Other surveyed tool was presented by Mulyasari et al., that includes four domains and indicators for improving the resilience of hospitals to the earthquakes in Japan (38). Analyzing this tool demonstrated that it is comprehensive in spite of having four domains. Three domains similar to HSI model and human resources added as the last domain. This tool emphasized on the power and water systems, but the buildings’ condition in hospitals and other utilities were neglected. Moreover, the main focus of human resources domain is just on medical staff and the other groups of hospital personnel have been neglected. The other disadvantage is focusing this tool on the preparedness phase while a resilient hospital system should cover different phases of disaster management including mitigation, preparedness, response and recovery (17).
The model proposed by Khanmohammadi et al., concentrate on the hospital building and relevant technical services failure after earthquakes at recovery phase in Iran. It cited the impacts of hospital damages and the resource shortage on the quality of services and used the relevant variables to quantify the resilience of the hospitals (33). The model variables were classified into three groups including the endogenous, exogenous and excluded variables. The endogenous variables can influence the building damages, the exogenous variables including earthquake intensity and the excluded variables that would help to quantify the functionality of hospital.
Zhong suggested a framework including four domains and 12 subdomains for assessing hospital resilience assessment in China (22, 51). This framework highlighted the management and function of hospitals more than the structural and non-structural systems through disasters. Continuity of essential medical services as one of the domains of this framework only mentioned two fields of emergency medicine and surge capacity while continuity of services in hospital can include diverse areas such as utility services, staff participation and other similar fields. In this framework, all the building elements have been mentioned as the architectural components and there is no distinction between the windows and doors with medical and laboratory equipment or electrical installations. Moreover, the financial supports of the hospital system were neglected in mentioned framework. In Zhong study, the four basic resilience criteria including Robustness, Resourcefulness, Rapidity and Redundancy (4R) were applied as the performance criteria for categorizing the related domains to HDR (48).
With considering all advantages and disadvantages of HDR surveyed models and tools, in table 2, we tried to present a model to improve HDR in this systematic review.
Table 2: Domains, sub-domains and indicators of hospital disaster resilience
Indicators
|
Sub-Domain
|
Domain
|
Building Structural System, Retrofitting the building, Construction materials, Structural redundancy, Laboratory test results, Plan and vertical irregularities, Structural configuration and lateral resistance system, Structural integrity of the building, Building’s age, Soil type.
|
Stability
|
Constructive Resilience
|
Open spaces, Hazards maps and zones, The space between buildings, Proper zoning of building areas, Building regulations and design codes, Hospital design and layout (location, slope, sea level, water ground, seismicity, configuration etc.)
|
Design
|
Safety of internal path (stairs, corridors and elevators), Safety of the architectural elements such as doors, windows, internal and exterior walls, facings etc.
|
Architectural
|
Space for the ambulance stopping and passing, Safety of the access routes, Space for the helicopter landing, Capacity of hospital parking, Ramps for moving patients’ bed and for the people with disabilities.
|
Transportation and Transition System
|
Maintenance and safety of the electrical power systems, lightning systems and the generators, Automatic test equipments , Power conservation activities, The age of power systems, Continuous electric load analysis and monitoring, Redundancy for most critical areas, Monitoring systems for the power outage or power failure, Protecting from terrorist attack.
|
Power
|
Infrastructural Resilience
|
|
Maintenance and safety of the water system and the sewage system, Water saving and conservation activities, Time and length of water interruptions, The age of water and sewage system, Providing water from outside sources, Automatic test equipments, Plans for prioritize critical water consuming activities, Monitoring systems for water outage or water contamination.
|
Water and Sewage system
|
|
Maintenance and safety of IT and Communicationsystem, Automatic test equipments , Maintenance of alternative and backup communication and IT system.
|
Communication and IT System
|
|
Maintenance and safety of HVAC systems, Automatic test equipment, Monitoring systems to provide warning of HVAC system failure.
|
Heating, Ventilation and air conditioning (HVAC)
|
|
Fuel reservation, Safe location of the fuel storage.
|
Fuel
|
|
Maintenance and safety of the medical gas system, Providing alternative sources of medical gases.
|
Medical gas
|
|
Equipment anchorage and fixing, Safety of rooms' furniture and equipment, Safety of medical and laboratories equipments.
|
Equipment and furniture elements
|
|
Hazardous material forms and documents, Safety of hazardous solid waste, wastewater and liquid waste.
|
Hazardous Material
|
|
Condition and safety of the fire systems, Water supply for fire protection.
|
Fire system
|
|
Administrative Resilience
|
Disaster Plan
|
Emergency preparedness, Emergency response, Contingency plans, Emergency regulations, Emergency recovery, Emergency evacuation, Standard operating procedures (SOP).
|
Risk assessment and reduction
|
Hazards identification and analyses, Hospital initial condition, Structural and non-structural risk reduction measures, Estimation of structural and non-structural damages, Estimation of losses due to an interruption in services, Developing the measures for risk reduction in future.
|
Response
|
The proper response, Timely response, Early Warning.
|
Command
|
Establishing the incident command system (ICS).
|
Coordination
|
Create a framework for the participation of local authorities, Effective implementing information and communication system, The coordination between different parts of the hospital.
|
Evacuation
|
Proper and timely response according to the emergency evacuation plans.
|
Need assessment
|
Medical services demands, The rate of patient arrivals.
|
Logistic and supplies
|
Logistic management of requirements, Personnel recalling and transmitting system, Agreement with suppliers, Resources availability, Details of the types, amounts and quality of the equipment and stocks, Applying alternative systems in a safe mode.
|
Safety committee
|
Establishing and developing the emergency committee, List of personnel contact information, Human protection from fire, chemical and radiological hazards, Infection Surveillance, Prevention and control procedures, Insurance status.
|
Continuity of services
|
Preventing reduction in the system operation, Ability to adapt timely to emergency state, Self-organization and re-structuring.
|
Volunteers
|
Consider community-based activities, management and mobilization.
|
Finance
|
Management of the disaster financial and administration system Cost of repair and reconstruction, Mitigation budget.
|
Recovery
|
Maintenance and repair plan for equipment, Priorities of repair and reconstruction, Psychosocial services for emergency staff.
|
Training
|
Educational courses, Exercise, Promote research and studies, Lesson learned from past disasters.
|
According to our research aim that was determining the effective indicators on HDR, some indicators that were directly related to medical services such as triage or referral, transfer and reception of patients excluded in our review. Instead, the indicators that were described the structural and non-structural characteristics and also administrative and functional activities that relates to structural and non-structural systems included in this study. Totally, our suggestive model has 3 domains, 27 subdomains and relevant indicators for assessing HDR. The authors also tried to extract the relevant indicators that would be able to measure them quantitatively in the developed model for removing the weak point of qualitative models such as HSI. Also, the mentioned gap of Mulyasari tool was covered and we tried to extract the effective indicators in our suggestive model. The domains of model divided into three: constructive, infrastructural and administrative. Constructive resilience as a domain is developed structural issues that means all the elements of hospital’s building. This domain consists of architectural elements and the design of spaces and structures as subdomains for optimum function of hospitals to be inherently flexible, strong and adaptive to emergency situation. Another subdomain is transportation and transmission that should be designed before the hospital construction and facilitate the access of patients and staff to the hospital. The infrastructural resilience consisted of non-structural elements that facilitate the hospital functions. The utilities and services such as power, water or fire control have been mentioned with their relevant indicators in this part. In addition, the protection of electrical utilities from terrorist and cyber-attacks was highlighted as a subdomain in the infrastructural resilience. The administrative resilience domain includes activities for disaster management hospital such as hazard and vulnerability reduction measures, preparedness, response and recovery plans. In this domain, the management of the volunteers is also critical subdomain that shows us the importance of the community-based activities as well as participatory approach of resilience. Due to the importance of repair and reconstruction of the structural and utility systems, the cost and priorities of these actions have been mentioned as finance and recovery in the administrative resilience domain. Also, the domains and subdomains have the potential to substitute according 4R in this study. For instance, infrastructural resilience as a domain categorized into the resourcefulness and redundancy as the resilience criteria and demonstrates the hospital ability for mobilizing the alternative external resources and to apply human resources and material in the process of recovery and also to substitute alternative elements. Constructive resilience is associated with robustness as another resilience criterion that shows the ability of hospital system to withstand a given level of shocks. Extracted indicators relevant to recovery and response are accounted as rapidity as one of the resilience criteria that reflect the capacity of hospital system to meet priorities and achieve goals in order to recover functionality and avoid future disruption (27, 30, 59).
Limitations:
The main limitation of this review lies in the fact that only articles and documents in English were included. So, we may have lost some of the relevant research which was in other languages. Also, we had limited access to the full text of some papers that could be affected on finding comprehensive indicators. Identification and extracting the indicators in some articles especially in engineering fields was difficult. Also,The number of extracted indicators was high that we had to merge the similar indicators.