See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/334749880

Hospital Safety Index: Assessing the Readiness and Resiliency of Hospitals in

Indonesia

Article  in  Facilities · July 2019

DOI: 10.1108/F-12-2018-0149/full/html

CITATIONS READS

0 10

3 authors, including:

Riza Yosia Sunindijo Fatma Lestari

UNSW Sydney University of Indonesia
45 PUBLICATIONS   369 CITATIONS    36 PUBLICATIONS   125 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

US CRDF View project

Tree Risk Management at Universitas Indonesia View project

All content following this page was uploaded by Riza Yosia Sunindijo on 29 July 2019.

The user has requested enhancement of the downloaded file.

Published in: Sunindijo, R.Y., Lestari, F., and Wijaya, O. (2019). Hospital Safety Index:
Assessing the Readiness and Resiliency of Hospitals in Indonesia. Facilities. Available from:
https://www.emerald.com/insight/content/doi/10.1108/F-12-2018-0149/full/html.

Hospital Safety Index: Assessing the Readiness and Resiliency of Hospitals

in Indonesia
Riza Yosia Sunindijo, Faculty of Built Environment, UNSW Sydney, Australia,
r.sunindijo@unsw.edu.au

Fatma Lestari, University of Indonesia, Depok, Indonesia

Oktomi Wijaya, Universitas Ahmad Dahlan, Yogyakarta, Indonesia

Abstract

Purpose: This research aims to assess the hospital readiness and resiliency in a disaster-prone
Indonesia.

Design/methodology/approach: Hospital Safety Index, containing 151 items, was used to

assess 10 hospital in West Java and 5 hospitals in Yogyakarta.

Findings: The average level of Hospital Safety Index for the hospitals under investigation is
B, indicating that their ability to function during and after emergencies and disasters are
potentially at risk, thus intervention measures are needed in the short term. Hospitals in
Yogyakarta scored lowly in terms of their emergency and disaster management, even though
they have previously experienced major disasters in 2006 and 2010.

Practical implications: The role of the government is crucial to improve hospital readiness
and resiliency in Indonesia. It is recommended that they (1) identify disaster-prone areas so
that their hospital readiness and resiliency can be assessed; (2) assess the readiness and
resiliency of hospitals in the prioritised areas; (3) implement intervention measures; (4) re-
assess the readiness and resiliency of hospitals in the prioritised areas after implementing
intervention measures; and (5) develop a framework to ensure that the hospitals can maintain
their level of readiness and resiliency over time.

Originality/value: Research on hospital readiness and resiliency in Indonesia is still limited

despite the size of the country and its proneness to disasters. This research has investigated
the feasibility and value of using Hospital Safety Index to assess hospital readiness and
resilience in Indonesia.

Keywords: disaster management, Hospital Safety Index, Indonesia, readiness, resiliency.

Introduction

Achieving hospital disaster resilience is an aspiration that started more than 30 years ago
(Samsuddin et al., 2018). In 1981, the World Health Assembly passed a resolution that shows
the need to be proactive, rather than reactive, by establishing preventive measures and
preparedness for emergencies. During the International Decade on Natural Disaster
Reduction from 1990-1999, further resolutions endorsed the importance of preparedness in
the health sector (World Health Organization, 2007).

In 2005, at the World Conference for Disaster Reduction in Japan,168 countries approved the
Hyogo Framework for Action. The framework is the first plan to explain, describe, and detail
the work required from all different sectors and stakeholders to reduce disaster losses. Its aim
is to significantly reduce disaster losses by building the resilience of nations and communities
to disasters, which translates to reducing the losses of lives and social, economic, and
environmental assets when disasters strike. One of the goals of the framework is to promote
‘hospitals safe from disasters’ by ensuring that all new hospitals are built to a level of safety
that will allow them to function in disaster situations and implement mitigation measures to
reinforce existing health facilities, particularly those providing primary health care
(International Strategy for Disaster Reduction, 2007).

Indonesia, a country with more than 17,000 islands, faces an unusually high number of
hazards. Located on the Pacific ‘Ring of Fire’ where 90% of the world’s earthquakes occur,
Indonesia experiences a high degree of seismic activity. Fault lines exist throughout the
country and 15% of the active volcanoes in the world are in Indonesia, making earthquakes,
volcanic eruptions and tsunamis regular hazards in the country (James, 2008; Zoraster, 2006).
Indonesia also has approximately 5000 rivers in which 30% of them pass through urban
areas, including the capital Jakarta. Coupled with heavy rainfall, rubbish-clogged canals and
outdated water management systems, flooding is a considerable hazard in Indonesia. In
addition, deforestation, seismic activity and torrential rain contribute to frequent landslides
(James, 2008).

These hazards have the potential to destroy or damage hospitals and render them non-
functioning. For example, an earthquake in 2009 damaged 85 hospitals and health facilities in
Padang, West Sumatra (United Nations Office for Disaster Risk Reduction, 2010). Likewise,
after an earthquake hit Yogyakarta in 2006, 17 hospitals, considered among the best in
Indonesia, were closed in the Yogyakarta City. From a total of 117 health centres in the
Yogyakarta Province, 45 were destroyed, 22 were severely damaged and 16 were slightly
damaged. About 65% of the total damage and losses in the healthcare sector was suffered by
private practices and hospitals (Elnashai et al. 2006).

Hospitals are important infrastructure that should always remain safe and operational. Their
continuous operations are particularly important in disaster management. In this case, a safe
hospital is a facility whose services remain accessible and functioning at maximum capacity,
and with the same infrastructure, before, during, and immediately after disasters (World
Health Organization, 2015). As such, there is a need to assess the readiness and resiliency of
hospitals in Indonesia.

The Hospital Safety Index is an important tool for moving closer to the goal of hospitals that
are less vulnerable, safer and better prepared for emergencies and disasters. The tool
estimates the operational capacity of a hospital during and after an emergency and also helps
authorities determine hospitals most urgently need actions to improve their safety and
functionality. The Hospital Safety Index contains 151 items, which are divided into four
modules (World Health Organization, 2015):
1. External and internal hazards affecting the safety of the hospital and the role of the
hospital in emergency and disaster management.
 2. Structural safety to determine if the structure meets standards for providing services to
the population even in cases of major emergency or disaster, or whether it could be
affected in a way that would compromise structural integrity and functional capacity.
3. Non-structural safety, such as architectural elements, emergency access, utilities, and
critical equipment.
4. Emergency and disaster management to evaluate the level of preparedness of a
hospital’s organisation, personnel and essential operations to provide patient services
in response to an emergency or disaster.

Since its introduction in 2008, the Hospital Safety Index has gained traction in disaster-prone
countries globally. Twenty-eight countries and territories in Latin America have been using
the Index and, among them, eight countries have established a national safe hospitals
program. Intervention measures have been implemented by most hospitals in the region that
obtained low index scores (Ugarte, 2011). In Europe, the Hospital Safety Index has been used
to assess more than 140 hospitals in nine countries and to identify the most effective
mitigation measures for emergencies. Moldova and Georgia have integrated the index into
hospital accreditation and planning new hospitals. Tajikistan has used the index to
recommend improvements and to mobilise funding for improving vulnerable health care
facilities. Furthermore, the index helped Poland and Ukraine to develop, update and test their
hospital emergency plans (World Health Organization, 2012). In 2016, Hospital Safety Index
training took place in Kazakhstan (World Health Organization, 2016) and, the following year,
similar training was conducted in North Macedonia (World Health Organization, 2017). In
Iran, the Ministry of Health and Medical Education mandated the use of the index to assess
more than 900 hospitals and the findings were used to allocate resources and implement
interventions in facilities that required urgent improvements (Ardalan et al., 2014). On 1
January 2018, the first national standard of hospital accreditation came into effect in
Indonesia. One of the criteria in the standard states that hospitals should self-assess their
disaster readiness and resiliency using the Hospital Safety Index (Komisi Akreditasi Rumah
Sakit, 2017), showing the relevance of this tool in the context of this research.

Ensuring the functionality of hospitals in Indonesia and making them safe in the event of
disasters poses a major challenge, not only because of the high number of hospitals and the
high cost associated with implementing such improvements, but also because there is limited
information about their current levels of safety and emergency and disaster management.
Therefore, this research aims to evaluate the readiness and resiliency of hospitals in
Indonesia. The research objectives to achieve this aim are:
1. Identifying critical hospitals that will be evaluated in West Java and Yogyakarta
provinces.
2. Evaluating their readiness and resiliency in the event of disasters using the Hospital
Safety Index checklist.
3. Identifying areas that require improvements and providing recommendations to
improve their disaster readiness and resiliency.

Research Methodology

Quantitative methodology was adopted in this research as it aligns with the aim of the
research to quantitatively assess the readiness and resiliency of hospitals using the Hospital
Safety Index (HSI). Quantitative methodology is characterised by collecting numerical data,
using deductive reasoning, employing a natural science approach to explain social
phenomena, and having an objectivist conception of social reality (Bryman, 2016). In the
context of this research, numerical data were collected using the HSI to assess various items
that reflect the readiness and resiliency of hospitals in Indonesia. The research was done
deductively as it is based on the existing measurement framework used in the HSI. In this
case, the framework was employed to assess hospitals in Indonesia. As such, this research has
employed a natural science approach by collecting numerical data and using quantitative
analysis methods to explain the readiness and resiliency of hospitals in Indonesia. Likewise,
this research adopted objectivism ontology by assessing facts, i.e., levels of disaster readiness
and resiliency of hospitals, manifested by the conditions of the hospitals which were observed
in a structured manner.

Research method

The HSI is the tool used to assess the probability that a hospital will continue to function in
emergency situations based on structural, non-structural and functional factors, including the
environment and the health services network to which it belongs. It cannot replace detailed
vulnerability studies, but it is inexpensive and easy to apply, thus providing an initial step to
prioritising a country’s investments in hospital safety. Containing 151 items, the Hospital
Safety Index has four sections as presented in Table 1.

Table 1. The Hospital Safety Index (Source: World Health Organization, 2015)
Item
Module 1: Hazards and the role of
hospital in emergency and disaster
management
Module 2: Structural safety
2.1 Prior events and hazards
affecting structural safety
2.2 Building integrity
Module 3: Non-structural safety
3.1 Architectural safety
3.2 Infrastructure protection,
access and physical security
3.3 Critical systems
3.4 Equipment and supplies
Module 4: Emergency and disaster
management
4.1 Coordination of emergency
and disaster management
activities
Description
The hazards or dangers and geotechnical properties
of soils at the site of the hospital and hazards which
could lead to emergencies and disasters for which
the hospital would be expected to provide health
services in emergency response.
The structural integrity and functional capacity of
the hospital in cases of emergencies and disasters.
The hospital’s vulnerability to hazards and its
exposure to past hazards.
Damages occurred to the hospital in the past and
how they were repaired.
Non-structural elements critical to the functioning
of the hospital with particular attention on occupied
buildings and those that contribute most to acute
care services.
Architectural elements, such as doors, windows,
non-load bearing walls, partitions, and roofing.
Emergency access and exit routes to and from the
hospital.
Electricity, water supply, waste management and
fire protection.
Medical, laboratory, and office equipment, and
supplies used for analysis and treatment.
The preparedness of the hospital in response to
emergencies and disasters.
The level of organisation for coordination of the
hospital’s response to emergencies and disasters.
 Item
4.2 Hospital emergency and
disaster management response
and recovery planning
4.3 Communication and
information management
4.4 Human resources
4.5 Logistics and finance
4.6 Patient care and support
services
4.7 Evacuation, decontamination
and security
Description
Available plans and capacities for evacuation and
response (including patient-care services, mass
casualty management, triage and decontamination),
human, finance and logistical resources for disaster
preparedness and response, communication and
information management, availability of staff, and
safety and security of the staff.

The HSI Guide (World Health Organization, 2015) was used to determine the way to assess
each item. There were essentially three data collection methods to assess these HSI items:
structured observation, document review, and interview. For instance, structured observation
was used to evaluate item 20 (Module 3.1 architectural safety), the condition and safety of
doors, exits and entrances. In this case, the research team evaluated whether doors are
installed correctly and their ability to resist wind, fire, seismic and other forces. Doors, exits
and entrances should also be wide enough and free of obstacles to facilitate rapid movement
of people in emergencies. For assessing item 114 (Module 4.1 coordination of emergency and
disaster management activities), designated emergency and disaster management coordinator,
interview and document review were used. The research team checked whether a staff
member has been designated as the hospital disaster management coordinator and, if any,
review the document that shows the role and responsibilities of this coordinator.
Data collection location and sampling

West Java and Yogyakarta were provinces selected in this research. West Java is considered
as a disaster-prone province in Indonesia. In 2017, there were 163 natural disasters in West
Java, representing 14% of the total number of disasters among the 34 provinces in the
country. Yogyakarta, on the other hand, is the second smallest province in Indonesia after the
Jakarta Special Capital Region and is surrounded by the Central Java province, where 314
natural disasters occurred in 2017, the highest number among all provinces in Indonesia
(Badan Nasional Penanggulangan Bencana, 2018). Yogyakarta is also prone to experiencing
disasters. For example, in 2006, a 6.3-magnitude earthquake struck Yogyakarta, killing nearly
6000 people, destroying 300,000 houses and severely damaging another 300,000 houses
(McRae and Hodgkin, 2011). In 2010, Mt Merapi erupted and damaged four regencies in
East Java and Yogyakarta. The eruption killed 300 people and displaced 350,000 people (The
World Bank, 2012). Recently in 2017, the Governor of Yogyakarta declared a state of
emergency following several days of flooding, landslides and strong winds (Muryanto, 2017).

Non-probabilistic purposive sampling was used in this research. The sample was determined
based on the objective of the study and the access granted by local authorities. Data were
collected from 10 hospitals in West Java and five hospitals in Yogyakarta by a group of three
evaluators, consisting of a physician, a public health officer, and a civil engineer. The three
evaluators have expertise in hospital disaster management. Approximately three months were
needed to collect the data because the evaluators needed three days to collect data from one
hospital due to the extensive nature of the HSI.
Data analysis
Two analysis methods were employed to analyse the data. First, the HSI Guide (World
Health Organization, 2015) were used in data analysis to determine the overall score of a
hospital and its level of disaster readiness and resiliency. Each item in the HSI can be scored
either high, average, or low, in which the value of each level is 1, 0.5, and 0 respectively.
Following the guidelines, a consensus was then used by the evaluators to determine the value
of each item in the HSI. As an example, item 20 (Module 3.1 architectural safety), the
condition and safety of doors, exits and entrances, was evaluated by using the following
guidelines:
- Low = Doors, exits and entrances in poor condition, subject to damage which would
impede the function of this and other elements, systems or operations; entrance width
is less than 115 cm.
- Average = In fair condition, subject to damage but damage would not impede the
function of this and other elements, systems or operations; or entrance width is less
than 115 cm.
- High = In good condition, no or minor potential for damage that would impede the
function of this and other elements, systems or operations; and entrance width is equal
to or larger than 115 cm.

Second, multiple correspondence analysis (MCA) was used to detect and represent
underlying structures within the data. MCA allows a researcher to analyse the pattern of
relationships of several categorical dependent variables and is used to analyse a set of
observations described by a set of nominal variables (Abdi and Valentin, 2007). MCA is
advantageous because it does not require any distributional assumption and is a powerful
technique for pattern recognition and visual presentation of multiple categorial variables
(Costa et al., 2013; Roux and Rouanet, 2010). In order to conduct the analysis, the case study
hospitals were classified into classes A, B and C. In Indonesia, a class-A hospital is
considered as a top referral and a central hospital capable of providing a wide variety of
specialised and sub-specialised treatments. A class-B hospital is a provincial hospital capable
of providing a wide variety of specialised treatments and limited sub-specialised treatments.
A class-C hospital is a city-level hospital capable of providing limited treatments, which
include internal medicine, surgeries, paediatrics, and gynaecology (Khoirunisa, 2016).

Results and Discussion

Module 1 of the HSI is about identifying hazards that could lead to emergencies and
disasters. This module is not included in the calculation of the HSI, but the scoring of the
other modules is done with reference to the hazards identified in Module 1. In West Java and
Yogyakarta, geological and hydro-meteorological hazards are the relevant hazards. Common
geological hazards include earthquakes, volcanic eruption and landslides, while common
hydro-meteorological hazards include floods and landslides due to saturated soils.

Tables 2-4 present the dimensions of the remaining modules, which are the cores in
calculating the HSI. The maximum score indicates the number of items within that dimension
because a maximum value for an item is 1, i.e., assessed as ‘high’ as recommended in the
HSI guide. The average score is the average score for the 15 hospitals studied in this research.
Finally, the ratio was derived from dividing the average score with the maximum score.
Table 2. Structural safety scores
No Item Max score Average score Ratio
A1 Prior events affecting hospital safety 3 1.867 0.622
A2 Building integrity 15 9.167 0.611
Total 18 11.033 0.613

Table 3. Non-structural safety scores

No Item Max score Average score Ratio
B1 Architectural safety 15 9.867 0.658
B2 Infrastructure protection, access and 4 2.3 0.575
physical security
B3 Critical systems
a. Electrical system 10 6.167 0.617
b. Telecommunications system 8 4.600 0.575
c. Water supply system 6 3.533 0.589
d. Fire protection system 5 3.133 0.627
e. Waste management system 5 2.900 0.580
f. Fuel storage system 5 2.367 0.473
g. Medical gases system 6 3.867 0.644
h. Heating, ventilation and air 8 4.567 0.571
conditioning
B4 Equipment and supplies
a. Office and storeroom 2 0.500 0.250
furnishings and equipment
b. Medical and laboratory 19 10.067 0.530
equipment and supplies used for
diagnosis and treatment
Total 93 53.867 0.579

Table 4. Disaster and emergency management scores

No Item Max score Average score Ratio
C1 Coordination of emergency and 8 3.767 0.471
disaster management activities
C2 Hospital emergency and disaster 5 1.967 0.393
response and recovery planning
C3 Communication and information 4 1.700 0.425
management
C4 Human resources 5 1.667 0.333
C5 Logistics and finance 4 2.000 0.500
C6 Patient care and support services 9 3.100 0.344
C7 Evacuation, decontamination and 5 2.500 0.500
security
Total 40 16.700 0.418

Table 5 presents the overall HSI score. The weighting for each module was determined based
on the HSI guide (World Health Organization, 2015), which recommends that where there is
a higher risk of earthquake, the structural safety should have a weighting of 50%, the non-
structural safety 30% and the disaster and emergency management 20%. The index column
was calculated from multiplying the weight with the ratio of each module, while the overall
HSI was derived from the sum of the index scores. The overall HSI for the 15 hospitals
studied in this research was 0.544, which equates to level B. The interpretation of the index
score according to the HSI guide is as follows:
• HSI 0-0.35, level C: Urgent intervention measures are needed. The hospital is
unlikely to function during and after emergencies and disasters, and the current levels
of safety and emergency and disaster management are inadequate to protect the lives
of patients and hospital staff during and after emergencies or disasters.
• HSI 0.36-0.65, level B: Intervention measures are needed in the short term. The
hospital’s current levels of safety and emergency and disaster management are such
that the safety of patients and hospital staff, and the hospital’s ability to function
during and after emergencies and disasters, are potentially at risk.
• HSI 0.66-1, Level A: It is likely that the hospital will function in emergencies and
disasters. It is recommended, however, to continue measures to improve emergency
and disaster management capacity and to carry out measures in the medium- and
long-term to improve the safety level in case of emergencies and disasters.

Table 5. Overall hospital safety index score

No Module Weight (%) Ratio Index
A Structural safety 50 0.613 0.306
B Non-structural safety 30 0.579 0.171
C Disaster and emergency management 20 0.418 0.067
Overall hospital safety index 0.544
Level B

All three modules are classified as level B as indicated in the ratio column in Table 5 that
ranges from 0.418 to 0.613. This means that intervention measures are needed in the short
term for all modules to ensure that the hospitals are able to function during and after
emergencies and disasters. Reviewing the dimensions (Tables 2-4) within each module shows
that all dimensions are classified as level B, except office and storeroom furnishings and
equipment (B4a), human resources (C4) and patient care and support services (C6), which are
classified as level C because their HSI scores are less than 0.35.

First, in relation to office and storeroom furnishings and equipment (dimension B4a in Table
3), shelves should be anchored to the walls or braced and the contents are secured,
particularly when the hospitals are located in earthquake-prone areas. Furnishings and
equipment on wheels should be in the locked position and drawers should have latches to
keep them from sliding open. These furnishings and equipment should not obstruct
emergency access and evacuation routes.

Second, there are items related to human resources (dimension C4 in Table 4) that require
attention. An up-to-date contact list of all hospital personnel should be available. The actual
staffing levels of hospitals should meet the required staffing levels for normal functioning of
hospitals. There should be a procedure in place for mobilising and recruiting personnel to
meet demands during emergencies and disasters. A disaster response plan should have
instructions for assigning duties to personnel. Finally, there should be measures put in place
to ensure the wellbeing of hospital personnel during emergencies and disasters.

Third, during emergencies and disasters, patient care and other support services (dimension
C6 in Table 4) should be operational. This includes the ability to expand usable space for
mass casualty incidents, sufficient logistical supplies during major disasters, procedures for
the transfer and reception of patients during emergencies and disasters, a program to prevent
and control infection, and procedures for the management of dead bodies.

Table 6 Comparison of HSI in West Java and Yogyakarta

No Item West Java Yogyakarta
Ratio Level Ratio Level
A1 Prior events affecting hospital safety 0.550 B 0.767 A
A2 Building integrity 0.603 B 0.627 B
Module 2 total 0.594 B 0.65 B

B1 Architectural safety 0.660 A 0.653 B

B2 Infrastructure protection, access and physical 0.563 B 0.600 B
security
B3 Critical systems
a. Electrical system 0.625 B 0.600 B
b. Telecommunications system 0.575 B 0.575 B
c. Water supply system 0.592 B 0.583 B
d. Fire protection system 0.590 B 0.700 A
e. Waste management system 0.680 A 0.380 B
f. Fuel storage system 0.520 B 0.380 B
g. Medical gases system 0.708 A 0.517 B
h. Heating, ventilation and air conditioning 0.606 B 0.500 B
B4 Equipment and supplies
a. Office and storeroom furnishings and 0.175 C 0.400 B
equipment
b. Medical and laboratory equipment and 0.558 B 0.474 B
supplies used for diagnosis and treatment
Module 3 total 0.597 B 0.543 B

C1 Coordination of emergency and disaster 0.469 B 0.475 B

management activities
C2 Hospital emergency and disaster response and 0.470 B 0.240 C
recovery planning
C3 Communication and information management 0.488 B 0.300 C
C4 Human resources 0.370 B 0.260 C
C5 Logistics and finance 0.613 B 0.275 C
C6 Patient care and support services 0.400 B 0.233 C
C7 Evacuation, decontamination and security 0.600 B 0.300 C
Module 4 total 0.474 B 0.305 C

Overall Hospital Safety Index 0.553 B 0.527 B

Table 6 compares the indices between the 10 hospitals in West Java and 5 hospitals in
Yogyakarta. The overall HSI in these two regions can be classified as level B (0.553 in West
Java and 0.527 in Yogyakarta). However, there are differences between the two regions when
individual modules and dimensions are examined. Hospitals in Yogyakarta obtained level A
in prior events affecting hospital safety (A1) and fire protection system (B3d). However, they
scored poorly in nearly all dimensions in Module 4 related to disaster and emergency
management. On the other hand, hospitals in West Java obtained level A in architectural
safety (B1), waste management system (B3e) and medical gases system (B3g), and obtained
level C for office and storeroom furnishings and equipment (B4a).

The low indices of Module 4 for the hospitals in Yogyakarta are concerning, especially after
the major earthquake in 2006 and the eruption of Mt Merapi in 2010. It seems that even after
experiencing major disasters, the readiness and resiliency of hospitals is still relatively low.
Module 4 is important because it is strongly related to the ability of hospitals to perform
during and after major events. For instance, after an earthquake in Yogyakarta in 2006, 30%
of tetanus patients died because of the infection (Sutiono et al., 2009), indicating a lack of
patient care and support services (dimension C6). Due to the proneness of Yogyakarta to
experiencing disasters, the government should urgently implement intervention measures to
improve this particular aspect and ensure that hospitals in Yogyakarta remain safe and
operational during and after disasters.

As explained in the data analysis subsection, case studies hospitals were classified into class
A, B, or C, and MCA was used to further analyse the data and find the relationship among
categorical variables. Among the case study hospitals, there were 1 class-A, 2 class-B, and 2
class-C hospitals in Yogyakarta; and 1 class-A and 9 class-B hospitals in West Java. The
model summary for the MCA analysis is presented in Table 7, while the joint plot of category
points is presented in Figure 1. The model summary shows that the two-dimensional space
captures a representative 98.79% of the total variance in the data set and each dimension
yielded an eigenvalue higher than 1. Dimension 1 represents the level of HSI, while
dimension 2 represents the case study locations.

Table 7 Model summary

Variance Accounted For
Cronbach’s Total
Dimension Alpha (Eigenvalue) Inertia % of Variance
1 .809 2.834 .567 56.688
2 .656 2.105 .421 42.098
Total 4.939 .988
a
Mean .744 2.470 .494 49.393
a. Mean Cronbach’s Alpha is based on the mean Eigenvalue.
 Figure 1 Joint category plot

The joint category plot reveals two combination clouds formed by categories that are closely
related. The first combination cloud shows that class C hospitals located in Yogyakarta have
poor disaster management (Module 4). This result reinforces the low indices of HSI Module
4 among hospitals in Yogyakarta. Despite experiencing major disasters in the past 10 years,
the readiness and resiliency of hospitals, particularly class C hospitals, in Yogyakarta still
needs urgent improvements. The second combination cloud also strengthens the previous
result by indicating that class B hospitals in West Java have medium HSI indices (level B) for
all three modules. Lastly, this result implies that class C hospitals in Indonesia tend to have
low HSI indices, thus requiring urgent improvements to ensure that they remain operational
during major disasters and emergencies.

Lessons Learnt

There are some important lessons that can be learnt from conducting this research. These
lessons were drawn from the process of conducting this research and from the data analysis
results. First, HSI is not a tool to conduct a detailed vulnerability study. However, this tool
consists of 151 items and still requires a significant time commitment to be administered. The
research team needed at least two days to collect data from one hospital. In fact, three days
were required for the majority of the hospitals investigated in this research to ensure that the
data collection process did not disrupt the operation of the hospitals.

Second, HSI is a valuable tool to assess the readiness and resilience of hospitals in the event
of emergencies and disasters, and to identify aspects that require improvements. The hospitals
and the government can use the outcomes to prioritise and implement critical intervention
measures to improve the performance of the hospitals.
Third, HSI is a powerful tool to benchmark hospitals. A state or provincial government can
benchmark the hospitals under their administration and prioritise their budget to implement
intervention measures in hospitals that are prone to experiencing emergencies and disasters or
that need urgent improvements.

Fourth, the HSI scores of the 15 hospitals under investigation show the need to building
capacity and a comprehensive framework for preparedness and mitigation, rather than relying
on a reactionary approach as reflected by the low indices. In most cases, hospitals cannot do
this on their own without the support from various key stakeholders, particularly from the
government. James (2008) recommended three strategies to improve disaster preparedness
and mitigation in Indonesia. First, building government capacity to ensure its ability to meet
its obligations. Enhancing disaster-resistance information, the use of communications
technologies and creating a culture of preparedness at the national, provincial and district
level governments are needed. Second, better coordination with the international community
to provide funding and technical input to improve the country’s disaster management
capability. Third, increasing public awareness and involvement to adopt a community-based
approach to disaster management. This capacity building, particularly at the local level,
allows the implementation of a more decentralised model in disaster management that has
been proven successful (Gatignon et al., 2010).

Conclusions

It is crucial for hospitals to remain operational during and after major events and disasters.
Hospital readiness and resiliency is particularly important for Indonesia, a disaster-prone
country. Using the Hospital Safety Index assessment tool, this research assessed 10 hospitals
in West Java and five hospitals in Yogyakarta. The overall HSI in this research is 0.544 (level
B), which indicates that intervention measures are needed in the short term because the
hospitals’ ability to function during and after emergencies and disasters are potentially at risk.

Assessing the two regions separately reveals that the HSI in West Java is 0.553, while
Yogyakarta is 0.527; both were level B. However, there are considerable differences between
the two regions when individual modules are examined. The HSI score of the disaster and
emergency management module in hospitals in Yogyakarta is 0.305 (level C), indicating that
the hospitals are unlikely to function during and after major disasters and emergencies, thus
requiring urgent improvements. This finding is alarming because it seems that after
experiencing major disasters in 2006 and 2010, hospitals are still not ready to face major
events.

The following are the recommendations for the Indonesian Government to promote hospital
readiness and resiliency:
1. Identify disaster-prone areas so that their hospital readiness and resiliency can be
assessed. This prioritisation is essential given the possible budget constraint.
2. Assess the readiness and resiliency of hospitals against major disasters and
emergencies in these prioritised areas.
3. Implement intervention measures as needed. Prioritisation again is required to ensure
that the budget is used wisely to achieve maximum outcomes. It should be noted that
some improvements can be achieved easily as long as hospital staff and government
officials are aware of the standard practices required from a hospital.
4. Re-assess the readiness and resiliency of hospitals in the prioritised areas after
intervention measures are implemented.
 5. Develop a hospital staff training framework to ensure that the knowledge gained is
kept in the hospitals where improvements have taken place so that they can maintain
their level of readiness and resiliency over time.
6. Repeat step one by identifying other disaster-prone areas.

It should also be noted that much research is still needed to assess the hospital readiness and
resiliency in Indonesia. Further studies can use other factors to further understand the
conditions of hospitals in the country, such as geographical locations, hospital classes, and
hospital status (private vs. public). Assessing hospitals prior and after major events can also
be conducted to study the reliability of the HSI and to assess hospital readiness scores in both
scenarios.

References

Abdi, H. and Valentin, D. (2007), Multiple correspondence analysis, In: Salkind, N. (Ed.)
Encyclopedia of Measurement and Statistics, Sage, Thousand Oaks, CA.

Ardalan, A., Kandi, M., Talebian, M.T., Khankeh, H., Masoumi, G., Mohammadi, R.,
Maleknia, S., Miadfar, J., Mobini, A., and Mehranamin, S. (2014), Hospitals safety from
disasters in I.R. Iran: The results from assessment of 224 hospitals, PLOS Currents, 28
February 2014, 6.

Badan Nasional Penanggulangan Bencana (2018), Data Informasi Bencana Indonesia, Badan
Nasional Penanggulangan Bencana, Jakarta, Indonesia.

Bryman, A. (2016), Social Research Methods, 5th ed., Oxford University Press, Oxford, UK.

Costa, P.S., Santos, N.C., Cunha, P., Cotter, J., and Sousa, N. (2013), The use of multiple
correspondence analysis to explore associations between categories of qualitative variables in
healthy ageing, Journal of Aging Research, 2013, 302163.

Elnashai, A.S., Kim, S.J., Yun, G.J., and Sidarta, D. (2006), The Yogyakarta Earthquake of
May 27, 2006, Mid-America Earthquake Center, Urbana-Champaign, IL, available at:
http://mae.cee.illinois.edu/publications/reports/Report07-02.pdf (accessed 30 October 2018).

Gatignon, A., Van Wassenhove, L.N., and Charles, A. (2010), The Yogyakarta earthquake:
Humanitarian relief through IFRC's decentralized supply chain, International Journal of
Production Economics, Vol. 126 No. 1, pp. 102-110.

International Strategy for Disaster Reduction (2007), Hyogo Framework for Action 2005-
2015: Building the Resilience of Nations and Communities to Disasters, International
Strategy for Disaster Reduction, Geneva, Switzerland.

James, E. (2008), Getting ahead of the next disaster: recent preparedness efforts in Indonesia,
Development in Practice, Vol. 18 No. 3, pp. 424-429.

Komisi Akreditasi Rumah Sakit (2017), Standar Nasional Akreditasi Rumah Sakit, Komisi
Akreditasi Rumah Sakit, Jakarta, Indonesia.
McRae, G. and Hodgkin, D. (2011), Half full or half empty? Shelter after the Jogjakarta
earthquake, Disasters, Vol. 35 No. 1, pp. 243-267.

Muryanto, B. (2017), Emergency status declared in Yogyakarta amid floods and landslides.
The Jakarta Post, 30 Nov 2017, available at:
http://www.thejakartapost.com/news/2017/11/30/emergency-status-declared-in-yogyakarta-
amid-floods-and-landslides.html (accessed 23 July 2018).

Khoirunisa, R. (2016), Mengenal perbedaan rumah sakit tipe A B C D dan E, Pasien BPJS,
Jakarta, Indonesia, available at: http://www.pasienbpjs.com/2016/06/mengenal-perbedaan-
tipe-rumah-sakit.html (accessed 7 December 2018).

Roux, B. L., and Rouanet, H. (2010), Multiple Correspondence Analysis, Sage, Washington,
DC.

Samsuddin, N.M., Takim, R., Nawawi, A.H., Aina, S.N. and Alwee, S. (2018), Disaster
preparedness attributes and hospital’s resilience in Malaysia, Procedia Engineering, Vol.
212, pp. 371-378.

Sutiono, A.B., Qiantori, A., Suwa, H. and Ohta, T. (2009), Characteristic tetanus infection in
disaster-affected areas: case study of the Yogyakarta earthquakes in Indonesia, BMC
Research Notes, Vol. 2 No. 34.

Ugarte, C. (2011), The WHO safe hospitals initiative, Pan American Health Organization,
available at: http://www.ehcca.com/presentations/emsummit5/ugarte_ms1.pdf (accessed 07
May 2019).

United Nations Office for Disaster Risk Reduction (2010), Indonesia Pledges Safety of Over
3,000 Schools and 100-plus Hospitals, United Nations Office for Disaster Risk Reduction,
available at: https://www.unisdr.org/archive/14779 (accessed on 21 April 2017).

The World Bank (2012), REKOMPAK: Rebuilding Indonesia’s Communities After Disasters,
The Secretariat of the Multi Donor Fund for Aceh and Nias and the Java Reconstruction
Fund, Jakarta, Indonesia.

World Health Organization (2007), Mass Casualty Management Systems: Strategies and
Guidelines for Building Health Sector Capacity, World Health Organization, Geneva,
Switzerland.

World Health Organization (2012), WHO’s hospital safety index and emergency checklist
rolled out in Europe, World Health Organization, Geneva, Switzerland, available at:
http://www.euro.who.int/en/health-topics/emergencies/pages/news/news/2012/10/whos-
hospital-safety-index-and-emergency-checklist-rolled-out-in-europe (accessed 07 May 2019).

World Health Organization (2015), Hospital Safety Index: Guide for Evaluators, 2nd ed.,
World Health Organization and Pan American Health Organization.

World Health Organization (2016), Preparing for Disaster – hospital safety index training
takes place in Kazakhstan, World Health Organization Geneva, Switzerland, available at:
 http://www.euro.who.int/en/countries/kazakhstan/news/news/2016/10/preparing-for-disaster-
hospital-safety-index-training-takes-place-in-kazakhstan (accessed 07 May 2019).

World Health Organization (2017), Hospital Safety Index training in the former Yugoslav
Republic of Macedonia. World Health Organization, Geneva, Switzerland, available at:
http://www.euro.who.int/en/health-topics/Health-systems/pages/news/news/2017/05/hospital-
safety-index-training-in-the-former-yugoslav-republic-of-macedonia (accessed 07 May
2019).

Zoraster, R.M. (2006), Barriers to disaster coordination: health sector coordination in Banda
Aceh following the South Asia Tsunami. Prehospital and Disaster Medicine, Vol. 21 No. S1,
pp. S13-S18.

View publication stats