This study aimed to determine the domains and indicators for assessing HDR through a systematic review. Given that the proper and timely operation of hospitals is crucial in times of crisis; their resilience needs to be addressed. Therefore, the comprehensive assessment of HDR helps to find the weaknesses and challenges in the scope of disaster risk and remove them to mitigate the harmful consequences of disasters (59). The desirable performance of hospitals during and after disasters and their continuity to services depends on different factors, such as hospital building stability, including the structural and non-structural systems (60). Several studies were carried out in different fields of HDR, such as organizational resilience which is related to functional services of the hospital (1, 46, 61-63).However, the studies which are substantially related to structural and non-structural components of hospitals have been rarely found. Thus, a systematic method of HDR regarding the structural and non-structural systems would be required. Some indicators which were directly related to medical services, such as triage or referral, transfer, and reception of patients excluded in the present review. However, the indicators that described the structural and non-structural characteristics as well as administrative and functional activities concerning structural and non-structural systems included in this study. Most of the studies focused more on electrical and water utilities and transportation networks in hospitals (40, 42, 46, 51, 53, 54, 56, 58, 64). The literature showed that other utilities in hospitals like communication system, gas supply system, sewage system as well as 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 (65). Moreover, there is a crucial difference between risk reduction (safety and preparedness) and resilience in this regard. Safety is defined as “a state in which hazards and conditions leading to physical, psychological or material harm are controlled in order to preserve the health and well-being of individuals and the community”(66). However, resilience is defined as a concept for the ability or capacity of a system or community to deal with risk(67). Based on these definitions, it can be found that safety and risk reduction is mainly used to reduce the level of risk; however, resilience is used to keep control of the functionality of a system when the system is prone to risk. The model, tools, and framework in Table 2 had properties which helped to improve a model to assess HDR. The HSI tool and frameworks proposed by Zhong had an all-hazards approach (27, 33). The HSI has three sections, including structural, non-structural and disaster management system (27). The structural system refers to elements of building that withstand loads. Other elements of buildings, such as utilities and architectural systems are categorized as non-structural system. One of the advantages of this tool is that the non-structural section is wide and consists of many sub-categories. The disaster management category in HSI has emphasized on preparedness of the hospital system, including human resources readiness, preparing action plans, management of communication and information systems, patient care and support services, and logistics and finance. Another surveyed tool was presented by Mulyasari et al., including four domains and indicators for improving the resilience of hospitals against earthquakes in Japan (25). Analyzing this tool demonstrates that the proposed approach is not comprehensive in spite of having four domains. Three domains similar to HSI modeland human resources were also added. This tool focuses mainly on the power and water systems and not structural condition of hospitals and other utilities. Moreover, the main focus of human resources domain is just on medical staff, so that the other groups of hospital staff have been neglected. The other disadvantage is that this tool considers only the preparedness phase, while a resilient hospital system should cover different phases of disaster management, including mitigation, preparedness, response, and recovery(68).The model proposed by Khanmohammadi et al., concentrates on the hospital building and relevant technical services failure after earthquakes at the recovery phase in Iran. It cites the impacts of hospital damages and the resource shortage on the quality of services and uses the relevant variables to quantify the hospitals resilience (45). The model variables were classified into three groups, including the endogenous, exogenous, and excluded variables. The endogenous variables can affect the building damages, the exogenous variables, including earthquake intensity, and the excluded variables that would help to quantify the functionality of the hospital.
Zhong suggested a framework including four domains and 12 subdomains for assessing hospital resilience assessment in China(32-34). This framework highlights managerial aspect of hospitals more than the structural and non-structural systems at the time of danger. Continuity of essential medical services as one of the domains of this framework only takes two factors, i.e. emergency medicine and surge capacity; whereas service continuity should include utility services, staff participation, and other similar fields as well(34).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 has been neglected in the mentioned framework(33).
The idea of this study is to extract the relevant indicators which would be able to measure them quantitatively in the developed model for removing the weak points of qualitative models.
By considering all advantages and disadvantages of HDR surveyed models and tools, the indicators extracted from research studies in this systematic review were collected and categorized in Table 3. These indicators can be useful for assessing HDR.
Table 3: Domains, sub-domains and indicators of hospital disaster resilience
Indicators
|
Sub-Domain
|
Domain
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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, Reduced stress and fatigue, Withstand disaster-induced damage and disruption
|
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.), Permit and clearance process,Interstitial space for utility installations, Occupancy or usage type of different parts of hospital
|
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, Length of power outage.
|
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, Amount of consumable commodity.
|
Response
|
The proper response, Timely response, Early Warning, Ability to discharge noncritical patients.
|
Command
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Establishing the incident command system (ICS).
|
Coordination
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Create a framework for the participation of local authorities, Effective implementing information and communication system, Access of operational personnel to expert opinions, Personnel partnership in finding solutions for defections, The coordination between different parts of the hospital. Accreditation standards, Performance of the other hospitals in the region. Dissemination of Personnel Incident Information to Staff During an Incident.
|
Evacuation
|
Proper and timely response according to the emergency evacuation plans.
|
Need assessment
|
Medical services demands, The rate of patient arrivals.
|
|
Logistic and supplies
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Logistic management of requirements, Personnel recalling and transmitting system, Agreement with suppliers, Resources availability, Mental health and psycho-social treatment for patients, families, and health workers, 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, Societal preparedness, Participation of donors community
|
Finance
|
Management of the disaster financial and administration system, Direct and indirect economic loss, 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
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Educational courses, Exercise, Promote research and studies, Lesson learned from past disasters.
|
Totally, the collected indicators were categorized in 3 domains, 27 subdomains, and relevant indicators that can be used for assessing HDR in future studies. The domains in Table 3were divided into three resilience types, including constructive, infrastructural, and administrative. Constructive resilience as a domain encompasses all elements of hospital 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 facilitates the access of patients and staff to the hospital. The infrastructural resilience consisted of non-structural elements which facilitate the hospital functions. The utilities and services, such as power, water or fire control were mentioned with their relevant indicators in this section. 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 included activities for disaster management hospital, such as hazard and vulnerability reduction measures, preparedness, response, and recovery plans. In this domain, managing the volunteers is also a critical subdomain which shows 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 were mentioned as finance and recovery in the administrative resilience domain. Also, the domains and subdomains have the potential to substitute according to 4R, including resourcefulness, redundancy, robustness, and rapidity. For instance, infrastructural resilience as a domain was categorized into the resourcefulness and redundancy as the resilience criteria demonstrate the hospital capability for mobilizing alternative external resources. It can also involve 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 which shows the ability of hospital system to withstand a given level of shocks. Extracted indicators relevant to recovery and response are accounted as rapidity which is one of the resilience criteria reflecting the capacity of hospital system to meet priorities in order to recover functionality and avoid future disruption (39, 42, 64).
Limitations
The main limitation of this review lies in the fact that English articlesand documents were only included. Therefore, the authorsmay have lost some of the relevant research studies which were in other languages. Furthermore, there were limited access to the full text of some papers that could affect finding comprehensive indicators. Identification and extracting indicators in some articles, especially in engineering fields, was difficult. Moreover, the number of extracted indicators wereconsiderably high that the authorshad to merge similar indicators.