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Risk Management and Healthcare Policy
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Developing a Hospital Disaster Risk Management
Evaluation Model
This article was published in the following Dove Press journal:
Risk Management and Healthcare Policy
Masoumeh Abbasabadi Arab1
Hamid Reza Khankeh1
Ali Mohammad Mosadeghrad2
Mehrdad Farrokhi1
1
Health in Emergency and Disaster
Research Center, University of Social
Welfare and Rehabilitation Sciences,
Tehran, Iran; 2Management and
Economics School of Public Health,
Tehran University of Medical Sciences,
Tehran, Iran
Purpose: Disasters are increasing worldwide and hospitals should be prepared to respond
well to such disasters. An effective hospital disaster risk management program saves
peoples’ lives, reduces damage to the hospital properties and assures hospital service
continuity. This article aimed to develop and verify a Hospital Disaster Risk Management
Evaluation model (HDRME).
Methods: A mixed-method explanatory sequential approach was used to develop and verify
the HDRME model. The first draft of the HDRME model was introduced through
a comprehensive literature review of major databases (i.e., PubMed, Scopus, Web of
Science, and Science Direct), using appropriate keywords. Furthermore, 18 in-depth individual interviews were conducted with well-known experts in DRM to identify more HDRME
constructs, sub-constructs, and standards. Then, three rounds of Delphi were conducted with
22 experts in hospital disaster risk management to verify the proposed model.
Results: The proposed HDRME consists of eight constructs, including seven enablers
(management and leadership; risk assessment; planning; prevention and mitigation; preparedness; response, and recovery) and one result (key performance results). These constructs
were further broken into 27 sub-constructs. The enablers and results scored 85% and 15% of
the model’s total scores.
Conclusion: A comprehensive conceptual framework for the evaluation of hospital disaster
risk management was introduced and verified. Standards and measurable elements can be
embedded in this conceptual model to measure a hospital’s preparedness in disasters and
accordingly, corrective actions can be taken to strengthen the hospitals’ responses to the
disasters. However, the proposed model should be validated in a hospital setting through
implementation.
Keywords: hospital, disaster, risk management, evaluation, model
Introduction
Correspondence: Hamid Reza Khankeh
Health in Emergency and Disaster
Research Center, University of Social
Welfare and Rehabilitation Sciences,
Kodakyar Street, Velenjak, Tehran, Iran
Tel +98 21 2218 0160
Fax +98 22 180 160
Email hamid.khankeh@ki.se
Disasters are inevitable and cause social and economic problems for the people and
governments. About 315 natural disasters occurred in 2018 and Asia experienced the
highest percentage of disasters (44%). Almost 68.5 million people were affected, and
11,804 deaths were reported, with an economic loss of US$131. 7 billion.1
International agreements have done for Disaster Risk Reduction and the building of
resilience to disasters in the world.2 Three international frameworks for disaster risk
reduction (DRR) are consist of: the Yokohama Strategy and Plan of Action for a Safer
World, the Hyogo Framework for Action 2005–2015, and the Sendai Framework for
Disaster Risk Reduction 2015–2030 (SFDRR). Disaster risk management (DRM) as
a comprehensive all-hazard approach develops and implements strategies for each
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com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By
accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly
attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
http://doi.org/10.2147/RMHP.S215444
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Abbasabadi Arab et al
phase of the disaster life cycle (i.e. Prevention and mitigation,
preparedness, response, and recovery).3,4
Hospitals play important roles in saving the lives and
reducing the suffering of injured people during and after
disasters. Hospitals are expected to create a safe environment for patients, visitors, and staff and provide health
care services to disasters’ casualties. Hence, an effective
hospital disaster risk management program should be
planned and implemented. However, the Iranian hospital
preparedness for disaster response is low and moderate.5–8
Evaluation is the regular review of program activity,
output, and outcome, with an emphasis on lessons
learned.3 The performance of hospitals’ DRM program
should be measured and assessed and accordingly corrective actions should be planned and implemented. There is
a persistent need for valid, reliable and comprehensive
tools for DRM evaluation. Systematic review studies on
hospital preparedness’s tools in the world have shown that
these tools do not meet all dimensions that required for
hospital preparedness.9–11 Also, despite advances in
research, program and plan development in the field of
hospital preparedness, there are no globally accepted standards for hospital DRM.3
There are many organization’ performance evaluation
models in the world, which use systematic models. These
models include a system of structural requirements, processes,
and outcomes for health care organizations that include
a number of primary and secondary dimensions.12 There are
few models for the DRM conceptual framework. The traditional disaster life cycle consisted of four phases (i.e.
Prevention and mitigation, preparedness, response and,
recovery)13 which address the process of disaster risk management. Nirupama (2013) identified seven domains as key elements of a comprehensive disaster risk management:
1-Threat recognition, risk and vulnerability Identification; 2Risk analysis and Assessment; 3- Risk control options, structural, non-structural, cost/benefit analysis; 4- Strategic
planning, economic, political and institutional support considerations; 5- Response, recovery, reconstruction, rehabilitation;
6- Knowledge management, sustainable development; and 7Resilience building, community participation.14,15 Zhong
(2014) developed a hospital resilience conceptual framework
consisted of four criteria, including redundancy, robustness,
rapidity and, resourcefulness.16
A comprehensive and systemic conceptual framework
for performance evaluation should be used to host DRM
standards and measurement elements. A DRM evaluation
model should consider the structures, processes and
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outputs/outcomes, which current DRM models have not
addressed. However, other elements such as leadership,
management commitment, funding, regulations, risk
assessment, planning, information system and partnership
with other organizations, etc. should also be considered in
any attempt to evaluate a hospital’s DRM program.17–20
Therefore, this study aimed to develop and verify
a comprehensive Hospital Disaster Risk Management
Evaluation model (HDRM) which introduce constructs,
sub-constructs, standards of DRM and evaluation tool for
DRM hospitals.
Materials and Methods
A Mixed-method explanatory sequential approach was
used in this study to develop and verify the HDRME
model. First, a critical review on major databases including PubMed, Scopus, Web of Science, and Science Direct,
using keywords including “evaluation models”, “hospital
disaster risk management”,” disaster risk management
model or framework”, “hospital Preparedness checklist”,
“hospital preparedness tools” was conducted to identify
the evaluation models, constructs and sub-constructs of
DRM. In addition, for identifying international and
national standards, a comparative study of Disaster Risk
Management accreditation standards of 10 countries
including USA, Canada, Australia, Malaysia, India,
Turkey, Thailand, Egypt, Saudi Arabia, and Denmark
was examined to extend the list of HDRME model constructs and sub-constructs. Furthermore, 18 in-depth individual interviews were conducted with well-known experts
in DRM to identify more HDRME constructs, subconstructs, standards, and measurable elements. Then, the
research team developed the first draft of the HDRME
model using the grounded theory.21
Finally, three rounds of a Delphi study were conducted
to verify the proposed HDRME model. The Delphi study
was performed between January and August 2018.
Twenty- two experts in hospital disaster management participated in this Delphi study. Experts were professors in
health in emergencies & disasters, the staff of the
Emergency Department in the ministry of health and disaster management center in universities of medical
sciences, Emergency Medicine Specialist and Secretary
of the DRM committee in hospitals. Twenty- two experts
completed the first round, and 21 experts completed
the second and the third rounds. The Delphi panelists’
key demographic characteristics are presented in (Table 1).
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Abbasabadi Arab et al
Table 1 The Demographic Characteristics of Delphi Panel Experts
Demographic Variables
Frequency
Demographic Variables
(%)
Gender
Male
Female
Frequency
(%)
Work experience in DRM
14 (63.6)
8 (36.4)
Age
5 to 10 years
11 to 15 years
13(59.1)
6 (27.3)
15 to 20 years
3 (13.6)
30 to 39 years
10 (45.5)
Education
40 to 49 years
50 years or older
11 (50)
1 (4.5)
Bachelor of Science
Master of Science
2 (9.0)
5 (22.7)
Doctor of Medicine
3 (13.6)
Occupation
Academic
7 (31.8)
PHD, health in disasters
and emergencies
4(18.2)
Disaster management center in universities of medical
7 (31.8)
PhD, Management of health services
3 (13.6)
sciences
The emergency department in MOH
3 (13.6)
Emergency Medicine Specialist
3 (13.6)
Secretary of the DRM committee in hospitals
5 (22.7)
Post-Doc, health in disasters and
2 (9.0)
emergencies
The proposed HDRME model’s constructs and subconstructs were presented to the expert panel during the
first round of the Delphi study and they were asked to
comment on the model and its constructs and subconstructs. They were also asked to comment on the
rationality, comprehensiveness, suitability, and applicability of the proposed model in hospitals. Experts’ answers
were reviewed and incorporated in the second draft of the
model. The revised model was then, presented to the
Delphi panelists in the second round. They were asked to
give a score between 1 (very low) and 10 (very much) to
the HDRME model’s constructs, sub-constructs, its logic
and rationality, comprehensiveness, suitability, feasibility
and applicability in the hospitals. A score of 70% and
more (score 7 and 10) was considered as acceptable from
the panelist’s side.22,23 The results of the second round
were analyzed. The mean and standard deviation for each
question were calculated and sent back to the Delphi panelists for the third round. They were asked to give a score
between 1 and 10 to each question. The experts were also
asked to give a weight to each construct of the HDRME
model out of 100.
Results
The preliminary HDRME model consisted of nine constructs (management and leadership, risk assessment, planning, staff management, patient management, resource
Risk Management and Healthcare Policy 2019:12
management, safety and security, incident management,
and key performance results) and 38 sub-constructs
(Figure 1). The Delphi experts in the first round agreed
to keep constructs such as “management and leadership”,
“risk assessment”, “planning”, and “key performance
results in the HDRME model. However, about 81% of
experts believed that it would be better to add the DRM
cycle (i.e. Prevention and mitigation, preparedness,
response, and recovery) to the proposed model. Thus, the
DRM cycle constructs were substituted with the “staff
management”, “patient management”, “resource management”, “safety and security”, and “incident management”
in the HDRME model. For example, the sub-constructs of
“staff management” and “resource management” were
incorporated in the “preparedness”, “response” and
“recovery” constructs; the sub-constructs of “patient management” was incorporated in the “response” and “recovery” constructs; the sub-constructs of the “safety and
security” was merged in “prevention and mitigation”, and
“response” constructs, and finally, the elements of “incident management” was merged in the “preparedness” and
“response” constructs the HDRME model. The experts’
comments and suggestions were considered in the model
for further development. As a result, the HDRME model
was consisted of 8 constructs and 26 sub-constructs
including “management and leadership”, “risk assessment”, “planning”, “prevention and mitigation”,
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Figure 1 The preliminary model of hospital disaster risk management evaluation model.
Figure 2 Conceptual framework of hospital disaster risk management evaluation (HDRME) model.
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Abbasabadi Arab et al
“preparedness”, “response”, “recovery”, and “key performance results”. (Figure 2).
The statistical result (mean scores and standard deviation) for the HDRME model, constructs and sub-constructs
are presented in (Table 2). The second round Delphi
results showed that the panelists did not agree with the
comprehensiveness and the rationality of the “risk assessment” and “planning” constructs and they achieved
a score less than 7. Experts provided some suggestions
on how to improve these constructs. Their comments were
considered in the model and the revised model with 8
constructs and 27 sub-constructs were presented to the
experts for further comments. The findings of the third
round showed that the Delphi experts were considered the
proposed model valid, comprehensive, suitable, feasible
and applicable to the hospitals. (Figure 3) shows the final
HDRME model constructs and sub-constructs. The results
of the model constructs’ weighting are presented in
(Table 3). The “Key Performance results” and “risk assessment” constructs had the highest scores among the
HDRME constructs. About 27 international standards
were extracted from the comparative study of hospital
DRM accreditation standards and interviewed by experts
added 30 national standards (totally 57 standards).24 These
standards added to construct and sub-constructs of
HDRME model. Final checklists were determined by
Table 2 The Statistical Result for HDRME Model, Construct and Sub-Construct of HDRME Model in Second and Third Round of
Delphi Study
Construct
Round 2
Round 3
(Mean, SD)
(Mean, SD)
1. How much do you think the relationship between model components are logical?
7.16 ± 0.98
8.5 ± 0.45
2. How much do you think the implementation of this model is possible in hospitals?
7.44 ± 0.7
8.4 ± 0.25
3. Do you agree that this model is comprehensive and intelligible for hospitals?
7.38 ± 1.37
7.9 ± 1.06
Is there a connection between the management and leadership Construct and its subconstructs?
7.56 ± 1.46
7.94 ± 1.35
Do the sub-dimensions of management and leadership cover all aspects of this
Construct?
7.28 ± 1.07
7.83 ± 1.54
Is there a connection between the Risk assessment Construct and its sub- constructs?
6.94 ± 1.26
7.84 ± 1.08
Do the sub-dimensions of Risk assessment cover all aspects of this Construct?
6.83 ± 1.29
7.92 ± 1.37
Is there a connection between the Planning Construct and its sub -constructs?
Do the sub-dimensions of Planning cover all aspects of this Construct?
7.61 ± 1.33
6.61 ± 1.14
8.01 ± 1.21
7.82 ± 1.04
Is there a connection between the Prevention and Mitigation Construct and its sub-
7.83 ± 1.29
7.92 ± 1.14
7.78 ± 1.17
7.85 ± 1.23
Is there a connection between the Preparedness Construct and its sub-constructs?
7.83 ± 1.15
7.96 ± 1.22
Do the sub-dimensions of Preparedness cover all aspects of this Construct?
8.22 ± 0.88
8.28 ± 1.08
Is there a connection between the Response Construct and its sub-constructs?
7.61 ± 1.04
7.93 ± 1.11
Do the sub-dimensions of Response cover all aspects of this Construct?
8.11 ± 1.28
8.19 ± 1.18
Is there a connection between the Recovery Construct and its sub- constructs?
7.83 ± 1.29
7.82 ± 1.14
Do the sub-dimensions of Recovery cover all aspects of this Construct?
7.89 ± 1.18
7.91 ± 1.01
Key Performance
Is there a connection between the Key performance results Construct and its sub-
7.72 ± 1.27
7.87 ± 1.32
Results
constructs?
7.94 ± 1.16
7.94 ± 1.16
Model
Management and
leadership
Risk Assessment
Planning
Prevention & Mitigation
Questions
constructs?
Do the sub-dimensions of Prevention and Mitigation cover all aspects of this
Construct?
Preparedness
Response
Recovery
Do the sub-dimensions of Key performance results cover all aspects of this Construct?
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Figure 3 Final construct and sub-constructs of (HDRME) model.
standards for each sub-constructs. (Figure 4) shows
the relationship between the HDRME model and the
standards.
Discussion
A comprehensive conceptual framework for hospital
disaster risk management evaluation (HDRME) was
introduced and verified in this study. The HDRME model
has eight constructs of which seven are enablers
(“Management and leadership”, “Risk assessment”,
“Planning”, “Prevention and mitigation”, “Preparedness”,
“Response”, and “Recovery”) and one is the result (“Key
performance results”). These constructs were further broken into 27 sub-constructs. These constructs and subconstructs cover the traditional DRM cycle and the elements of disaster risk management model introduced by
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Nirupama (2013) and the hospital resilience conceptual
framework developed by Zhong (2014). (Table 4) shows
the Comparison of HDRME model constructs with other
DRM models.
The HDRME model can be defined as “an integrated
system of principles, processes and best practices that provide a framework to improve hospital disaster preparedness”.
Management and leadership have critical roles in the
DRM. Hospital managers’ commitment, involvement,
and support, allocating resources to implement plans,
and developing community involvement programs are
important for the success of the DRM program. Senior
managers should pay more attention to the prevention
stage of the DRM and enhance the safety of the hospital
environment. They must create a safe and sustainable
environment for patients and staffs through developing
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Abbasabadi Arab et al
Table 3 Constructs and Score of HDRME Model
Construct
Sub-
Delphi Panel’s
Final
construct No
Score
Score
3
137
130
Risk assessment
Planning
3
2
142
127
150
120
Prevention and
3
129
120
mitigation
Preparedness
3
111
120
Response
Recovery
6
4
132
97
110
100
Key performance
3
125
150
results
Total points
27
1000
1000
Management and
leadership
guidelines and standards for various hospital departments and units. Hospitals need a well-established structure for the DRM such as the DRM committee, the
incident command system (ICS) and the hospital command center (HCC). Furthermore, a good external relationship should be established with community relief
organizations.25 A hospital’s capability to provide the
best healthcare services to casualties during a disaster
is dependent on its capability to effective coordination
with other organization and service providers.26 One of
the key elements of the Conceptual Framework of
Healthcare Resilience Zhong & et al is “Emergency
Leadership and coordination” that pay attention to hospital collaboration with other agencies.22 Initiating and
developing a could help hospital managers to use their
resources and technical assistance for disaster situation
management.
Disaster planning starts with hazards vulnerability analysis and risk assessment to explore the most probable
hazards in a hospital, prevent and mitigate the effects of
the hazards on the hospital’s structural and non-structural
elements.3 This key construct involves identifying the
risks of natural and man-made hazards and recognizing
vulnerable elements of the organization. Risk assessment,
using quantitative or qualitative data, estimate the levels of
the risk and develops plans. Risk assessment should not be
limited only to the prevention and mitigation phase of the
DRM cycle. It has to cover the whole disaster management
cycle, including preparedness, response, and recovery,
especially in cascade events.
Planning is also important in the DRM. Planning determines how managers establish a long-term vision, develop
the values required for long-term success of the hospital,
set DRM goals and objectives, and implements them via
appropriate policies and action plans. A comprehensive
hospital disaster plan should consider all hazards, all
DRM phases, and all levels of the hospital. The hospital
DRM plan should be implemented thoroughly and
reviewed on a regular basis. Resources should be available
to the lower managers and employees to implement the
DRM plan.8 The plans must be exercise and revised if it
was necessary.
The first stage of the disaster life cycle is related to the
prevention and mitigation to reduce the severity of an
event. It also includes actions that reduce potential physical damage to facilities during an event. Hence, at this
stage, the safety of hospital’s structural and non-structural
elements should be enhanced to reduce the effects of the
hazards.
Preparedness is defined as the knowledge and capacities
developed by governments, recovery organizations, communities and individuals to effectively anticipate, respond,
and improve, likely effects, impending an Accidents or
Dangerous Areas.27 It includes actions such as early warning systems, surge capacity, response strategies, disaster
exercises, and training. Surge capacity is defined as the
ability of an organization to expand rapidly and augment
services in response to one or multiple disasters.28 The
provision of support services plays a key role in the success
of hospitals in disasters. Hospitals with more precise support provision plans were more successful in responding to
disasters.20 Early warning system is the first component of
every response plan.29 The Sendai Framework for Disaster
Risk Reduction 2015–2030 (SFDRR), early warning system was considered as an important special goal.2 Staff
training and exercises are crucial in enhancing hospital
employees’ preparedness.
Figure 4 The relationship between the HDRME model and the standards.
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Table 4 The Comparison of HDRME Model Constructs with Other DRM Models
HDRME Model
Traditional DRM Life
Comprehensive DRM; Nirupama14
Cycle
Conceptual Framework of
Healthcare Resilience; Zhong
et al16
Management and leadership
Emergency leadership and
cooperation
Risk Assessment
Risk analysis and assessment
Planning
Strategic planning -economic, political and
Disaster plans
institutional support considerations
Prevention and Mitigation
Prevention and Mitigation
Risk control options -structural, non-
Hospital Safety
structural
Preparedness
Preparedness
Emergency training and drills
Disaster stockpiles and logistics
management
Response
Response
Recovery
Recovery
Response, recovery, reconstruction,
rehabilitation
Emergency service capability
Recovery, evaluation, and
adaptation
Key Performance Results
Knowledge management, sustainable
development resilience building,
community participation
Response refers to the immediate and ongoing activities, programs and tasks, eg incident command system
activation, casualties’ triage, and management, staff &
volunteers’ management, resource management, information management, safety & security. Good pre-event planning, and efficient resource coordination and allocation are
critical to the success of the response stage.17 Volunteers’
management in disasters including identifying, supervising
and evaluating their performance, is also of great
importance.
Recovery covers restoration, reconstruction, and
improvement of facilities, livelihoods and living conditions
of affected communities. Recovery was given a higher priority in the development of standards. In this dimension, business continuity of services had addressed only in the
accreditation standards of the pioneering countries.
Moreover, paying attention to the personnel and their mental
recovery is one of the overlooked dimensions of sustainable
development.
Key performance results measure the performance of the
hospital in disasters in terms of the effects of the DRM on
organization, employees, and the society using output, outcome and impact key performance indicators. A systematic
review concluded that there is a lack of post-disaster
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evaluations.30 The Nirupama DRM model focuses on the
consequences of DRM, including Resilience building, community participation, sustainable development and knowledge management.14
Weighting to model constructs was determined by
national experts, with 85% devoted to enablers and
15% to results. Since in our country, we are still at the
beginning of implementing DRM processes and it takes
more time to achieve key performance results. The
weight of each of constructs of HDRME model can be
changed depending on status and importance in other
countries.
Conclusion
The hospital disaster risk management evaluation model is
a logical and systematic framework for evaluating the structures, processes and outputs/outcomes of a hospital disaster
risk management. This study sets out to introduce and
develop a comprehensive conceptual framework and
a systemic approach to DRM and logic relation between
key constructs. The HDRME can be used as a selfassessment framework by hospital managers to recognize
their DRM strengths and weaknesses and accordingly apply
corrective actions. It shows a clear picture of a hospital’s
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preparedness for disasters. It also can be used for comparing
the DRM programs of various hospitals in a region.
Study Limitations and Implications
for Future Research
A comprehensive HDRM model was developed using an
intensive literature review and in-depth interviews and verified by DRM experts. However, the proposed model should
be validated in a hospital setting through implementation.
Ethics Approval
This article was taken from a doctoral thesis and was
approved by the University of Social Welfare and
Rehabilitation Sciences Ethics Committee, with approval
code IR.USWR.REC.1396.290.
Acknowledgments
The authors would like to thank the distinguished referees
who contributed to the quality of this paper with their
constructive comments. The authors also acknowledge
Dr. Akbar Biglarian who was a member of the research
team and the statistic co-supervisor, for their contributions
to this work.
Disclosure
The authors report no conflicts of interest in this work.
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