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Original Article

Hospital safety index (HSI) analysis

in confronting disasters: A case study
from Iran
Katayoun Jahangiri, Yasamin O. Izadkhah1, Azam Lari2
Department of Family Health, Health Metric Research Center, Iranian Institute for Health Sciences Research,
Iranian Academic Center for Education, Culture and Research, Tehran, Iran, 1Risk Management Research Centre,
International Institute of Earthquake Engineering and Seismology, Tehran, Iran, 2Department of Health Services
Management, Science and Research Branch, Azad Islamic University, Tehran, Iran

Abstract
Background: The ability of hospitals to continue functioning without interruption in disaster situations is a matter of life and death.
The Hospital Safety Index (HSI) provides an overview of the probability of a hospital or healthcare facility to remain operational in
emergency situations. Aims: This study has been performed in one of the hospitals associated with Social Security Organization in
Tehran in order to assess the HSI in disasters. HSI helps authorities to quickly determine where interventions can improve safety.
Materials and Methods: In this applied study, both qualitative and quantitative methods were used. Settings and Design: A specialized
hospital in Tehran was studied regarding its structural, nonstructural and functional aspects using the World Health Organization/Pan
American Health Organization (WHO/PAHO) standard checklists. Various wards and personnel of the hospital were included in
this study. Statistical Analysis Used: Different types of hazards were analyzed, which are related to the location of the hospital. For
determining the amount of risk in different wards, the occurring probability of each risk was scored based on the section status,
previous records and events according to the Likert scale in one of the 4 levels and the total scores was considered as the section
risk amount. Afterward, among each sections with similar tasks (administrative, financial, managerial and professional, supportive,
clinical, surgery room and intensive care unit, emergency unit, and inpatient sections), the least and most amount of risk were clarified
with regard to the following scores. Regarding the total scores, the minimum risk amount was 17 and the maximum was 68 in each
section. If the total score was less than 17, no risk (safe), 17‑34 low risk, 35‑52 moderate risk, and in case of 53‑70, the high risk
was considered for that section. Results: According to the results, the final Hospital Safety Index score places this hospital in category
“C” among three existing classifications of safety, which means that the hospital’s current safety levels are inadequate to protect
the lives of patients and hospital staff during and after a disaster. Conclusions: Urgent intervention measures and rapid assessment
will give decision‑makers a starting point to identify priorities in order to reduce risk and vulnerability in hospitals and health care
facilities.
Key words: Disasters, functional capacity, Hospital Safety Index, nonstrutural safety, strutural safety

Address for correspondence: Introduction

Prof. Katayoun Jahangiri,
Department of Family Health, Health Metric Research Center, The Hyogo Framework for Action 2005-2015 (HFA)
Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran. included the following measure in order to reduce the
E-mail: katayounjahangiri@yahoo.com underlying risk factors as a part of social and economic
development practices:
Access this article online
Quick Response Code: ‘Integrate disaster risk reduction planning into the
Website:
health sector; promote the goal of “hospitals safe from
www.ijhsdm.org
disaster” by ensuring that all new hospitals are built
with a level of resilience that strengthens their capacity
DOI: to remain functional in disaster situations and implement
10.4103/2347-9019.135368 mitigation, measures to reinforce existing health facilities,
particularly those providing primary health care’. It also

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Jahangiri, et al.: HSI analysis in confronting disasters: A case study from Iran
aims at protecting and strengthening critical public
facilities including physical infrastructure, clinics,
hospitals, etc.[1]
While crisis occurs, the vital services of society should be
able to support the crisis survivors especially in the minutes
and hours following an unexpected event.[2] Among the
organizations and involving institutes, healthcare facilities
especially hospitals play the most important role as an
essential facility for providing services to those needed.[3]
There is an expanded expectation that these centers must
be designed in a manner to be able to function during and
after a disaster.[4] According to PAHO (2008), in designing
new, safe hospitals, there are three safety objectives:
• To protect the life of patients, visitors, and hospital staff,
• To protect the investment in equipment and furnishings,
• To protect the performance of the hospital or the
healthcare facility.
The aim of the “Hospitals Safe from Disasters” strategy
is therefore to ensure that hospitals will not only remain
functional in case of a disaster, but that they can function
effectively and without interruption. In addition, hospitals
and health care facilities are highly vulnerable because
of the factors such as complexity, occupancy, critical
supplies, heavy objects, hazardous materials and external
dependence. The importance of hospitals can be seen in
the economic loss and damage they may face. A reliable
and comprehensive hospital assessment can be carried
out only by taking into account all three main categories
of vulnerability as in the following order: (a) structural;
(b) nonstructural; and (c) administrative/organizational.[5]
In order to achieve this assessment, the development
of the HSI is a very important step towards the goal of
less vulnerable hospitals. Building the safe hospitals,
which can keep their efficiency and function in crisis has
always been a serious challenge for countries. Therefore,
it is important to measure the safety level of hospitals in
disaster situations as a part to decrease the risk in health
section.[2] With HSI, an image of the current position and
probable scenarios in crisis occurring time will be obtained,
based on the structural, nonstructural and functional
aspects of a hospital. In this way, the response strength of
each system in major emergencies can be measured and
the necessary and needed information can be submitted
to the policy makers.[6] Therefore, HSI is not only a tool
for making technical assessments, but it also provides a
new approach to disaster prevention and mitigation for
the health sector. Calculating the safety score allows the
hospital to establish maintenance and monitoring routines
and consider various and necessary measures to improve
safety in the medium term.[2] Therefore, the reinforcement
of structural, nonstructural and functional components
of hospital, as the most important centers that should be
immediately answerable to crucial needs after disasters,
should be preferred.[7]
International Journal of Health System and Disaster Management | Vol. 2 | Issue 1 | Jan-Mar 2014
In this regard, the PAHO Disaster Mitigation Advisory
Group  (DIMAG) and national experts came together to
devise a method for quick and inexpensive evaluation
of hospitals. Using a checklist helps to assess different
variables and safety standards for a hospital. A  scoring
system assigns the relative importance of each variable,
which, when calculated, gives a numeric value to the
probability that a hospital can survive and continue to
function in a disaster. The HSI not only estimates the
functional capacity of a hospital during and after an
emergency, but it provides ranges that help authorities
determine which facilities do need urgent interventions.
Priority might be given to a facility where the safety of
occupants is determined to be at risk during a disaster
or to a facility where the equipment is at risk, and where
maintenance is needed. HSI is not an “all or nothing”
approach to hospital safety, but it allows for improvement
in a facility over time. The index does not replace an
in‑depth vulnerability assessment, but it helps authorities
to quickly determine where interventions can improve
safety. It also provides an overview of the probability of
a hospital or healthcare facility to remain functional in
emergency situation, taking into account the environment
and the health services network to which it belongs. As a
comparison, it is like an out‑of‑focus snapshot of a hospital
and it shows enough of the basic features to allow us to
quickly confirm or reject the presence of imminent risks.[2]
For this purpose, in this study it was tried to perform
measures for reducing the risk to people’s life and property
loss through HSI calculation in one of the Social Security
Organization hospitals in Tehran.
Materials and Methods
The case study in this paper is based on the applied research,
which has made use of both qualitative and quantitative
methods. Two forms were used: Form No. 1 consisted of
general information about the hospital (case study). Form
No. 2 included the “Safe Hospitals Checklist”. This checklist
is used for preliminary diagnosis of the hospital’s safety in
disasters. It includes 145 variables, each with three safety
levels: low, moderate, and high. It is divided into four
sections or modules:
• Geographic location of the hospital;
• Structural safety;
• Nonstructural safety;
• Functional capacity.
In this regard, different types of hazards were analyzed
(geological, hydro‑meteorological, social, environmental,
chemical and technical) which are related to the location of
the hospital. The extent of hospital exposure is considered to
be directly proportional to the probability of the occurrence
of a hazard and its magnitude. In this way, they can be
classified as high (high probability of a hazard taking
place or high‑magnitude hazard), moderate (moderate
probability of a moderate magnitude hazard) and low
(low probability or a hazard of low magnitude).[2]
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Jahangiri, et al.: HSI analysis in confronting disasters: A case study from Iran

Also for the structural safety analysis in this study, the
PAHO standard was used, in which HSI and risk‑taking
level can be determined. For input gathering and completing
the checklists, observations, survey and interviews were
also used.
The below formula was used for assessing the non‑structural
and functional vulnerability amount (based on PAHO).
TPL (total property loss) = [NL (1) + NM (2) + NH (3)]/NE
TLS (total life safety) = [NL (1) + NM (2) + NH (3)]/NE

The nonstructural risk rating included the following[5]: When NL, NM, NH are low, moderate and high, respectively
and NE is the number of elements.[8]
‘Life safety (LS) risk: The risk of being injured by the item.
This does not include the overall impact on safety systems in Internally, each of the services provided by the hospital
a building, such as loss of emergency power in a hospital or will be of greater or lesser importance in the management
loss of fire detection capability. These disruptions of service of an emergency. In an emergency situation, the importance
are covered under loss of function below: of medical services can be rated as: 1) dispensable,
• Property loss (PL) risk: The risk of incurring a repair 2) preferable, 3) necessary, 4) very necessary and
or replacement cost because of damage to the item. 5) indispensable [Table 1]. Using Table 1, the vulnerability
This property loss, as used here, includes the cost of of each section (low, moderate and high) was determined.
mending a broken pipe but not the indirect cost of Structural, non‑structural and functional factors were
damage due to leaked water, and includes the cost weighted based on their importance during the disaster
of repairing a computer but not any loss of business occurrence. These scores were 50% of the total score index
revenue due to computer downtime. These indirect for structural, 30% for non‑structural and 20% for functional
effects cannot be estimated here on a generic basis components.
• Loss of function (LF) risk: The risk that the item will not
function because it has been damaged. This includes
The vulnerability/consequences level is determined
some consideration of the impact of this loss of function
according to the ranges of TPL or TLF values given in
of the component on the operation of an ordinary
Table  2.[9] For input analysis, Statistical Package for the
occupancy building. Not included are off‑site effects,
Social Sciences  (SPSS version  16.0), statistical software
such as the loss of function of a piece of equipment
because of a citywide power cut. Losses of power, was used.
water and other utilities are real problems to consider
but are outside the scope of the item‑by‑item ratings To conclude, regarding the total score, hospitals and
here. healthcare facilities are in one of three of following
classification regarding safety,[2]:
For determining the amount of risk in different sections
of the hospital, the occurring probability of each risk Classification A: Those centers, which are considered to be
was scored based on the section status, previous records able to protect their residents safely and can continue their
and events according to the Likert scale in one of the activities in disasters are in this group (safety index 0.66‑1).
4 levels (no risk = 1, low risk = 2, moderate risk = 3,
high risk = 4), and the total scores was considered as the Table 1: Priorities of hospital sections regarding the safety
section risk amount. Afterward, among each sections condition in disastrous situations
with similar tasks  (administrative, financial, managerial Different sections in the hospital Importance
and professional, supportive, clinical, surgery room and Trauma section 5
intensive care unit, emergency unit, and inpatient sections), Intensive care 5
the least and most amount of risk were clarified with regard Emergency unit 5
to the following scores. Regarding the total scores, the Sterilization 5
minimum risk amount was 17 and the maximum was 68 in Pharmacy 5
Nutrition 5
each section. If the total score was less than 17, no risk (safe),
Transport 5
17‑34 low risk, 35‑52 moderate risk, and in case of 53‑70, the Recovery 5
high risk was considered for that section. Clinic 4
Laboratory 4
For examining the risk amount in structural dimension, Management office 4
(vulnerability category low = 2, moderate = 3, and high = 4) Radiology 1
were used. Then, using the average of total assessing items, Physiotherapy 1
the structural vulnerability level was clarified. Using PAHO
category, the vulnerability level of each section (low,
Table 2: Level of vulnerability/consequences
moderate, and high) is determined. When the total score was
2/5‑3/5, the hospital structural vulnerability was weak, in Low Moderate High
TPL (Total property loss) 1-1.7 1.7-2.3 2.3-3
case of 3/6‑4/5 it was moderate, and when it showed 4/6
TL (Total life safety) 1-1.7 1.7-2.3 2.3-3
and more, the vulnerability was considered in a high level.

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Classification B: In this group, there are centers that can
resist against a crisis, but their equipment and vital services
are exposed to danger (safety index 0.36‑0.65).
Classification C: Centers whose resident’s life and safety
are exposed to danger in crisis and urgent intervention
measures are needed (safety index 0‑0.35).
The HSI of the under‑examined hospital will be explored
more in the following sections.
Results
In general, it can be said that natural disasters are not
considered as the only cause of functional and physical
collapse of a facility and the probable resulting deaths.
Most of the time, hospitals are built without considering
the hazard risks into account and when maintenance
is neglected, systems deteriorate over time. Functional
breakdown is one of the main causes for service interruption
in hospitals after a disaster. Meanwhile, it should be
mentioned that only a small proportion of hospitals are put
out of service because of the structural damage.
In this study, the under examined hospital consisted
of 4 buildings, including various sections such as
clinic, emergency unit, admission unit and payment
office, ICU, operation room, laboratory, radiology,
physiotherapy, inpatient sections, nutrition unit, warehouse,
information technology, administrative and financial
units, transportation and equipment section, discharge
unit, income, facility management unit, library, clinical
engineering, and medical record office.
Based on the rapid visual assessment, the hospital structural
vulnerability was high, in which the highest vulnerability
level was related to building No. 1. For more precise results,
a quantitative assessment using architectural and engineering
methods is also needed which is not in the scope of this study.
Among the hospital different sections, the manager office,
transportation unit, pharmacy, and sterilization had the least
risk threat, and the medical record office, medical record
office, installations unit, laboratory unit, infectious disease
clinic and inpatient section had categorized at the highest risk.
In the non‑structural vulnerability from the equipment and
furniture dimensions, it was observed that the general clinic,
pharmacy, manager office, transportation, and intensive
care unit had the least vulnerability level and the infectious
disease clinic, physiotherapy; medical record office, clinical
engineering and inpatient section experienced the highest
vulnerability. As for nonstructural vulnerability, units from
the architecture dimension, cardiology and general clinics,
pharmacy, manger office, transportation, and the operation
room had the least vulnerability level and the infectious
disease clinic, physiotherapy, medical record office, clinical
engineering and the inpatient section had the highest level
of vulnerability.
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In functional vulnerability, from the disaster management
dimension, the general clinic and anesthetist consultant,
pharmacy, personnel unit, transport office, central
sterilization room (CSR) and inpatient section have the
least, and infectious disease clinic, laboratory, medical
record office, equipment and operation rooms and
emergency ward had the highest vulnerability level. In
functional vulnerability of units, from the resource aspect,
general clinic, pharmacy, sterilization and intensive care
unit had the least, and finally the infectious disease clinic,
physiotherapy, operation rooms and emergency care had
the highest vulnerability level.
Conclusion
In this study, the nonstructural vulnerability including
furnishing, administrative level and architecture equipment
was almost moderate but the architecture components
were more vulnerable. In this regard, Seyyedin et al.,[10] also
examined the vulnerability of a selective hospital facing a
disaster. From the nonstructural dimension, it was revealed
that the hospital vulnerability was at a moderate level.
It should be noted that for safety enhancement in equipment
and furniture sections, various stabilizing methods can
be used such as, shunts installation, using screwing bolts,
locking commodes, as well as fastening the shelves and
computer equipment to a proper wall.
Since destruction of architecture components during a
disaster could make a serious dysfunction in a hospital, it
is highly important to determine the vulnerability amount
of this component in hospital in order to decrease the
risk. Among the architecture components in this survey,
the entrance and exit routes, windows and glasses can be
mentioned. Shojaie[11] has examined the emergency exit
system in the educational hospitals of Iran Medical Science
University and has declared that emergency exit routes
have been almost determined in all hospital routes, but
the guiding signs and boards were not clearly observed
in all of them. In this study, none of the buildings in the
hospital had lead to emergency exit routes. Although, there
were more than one entrance and exit door in some parts
of the hospital, it was only possible to make use of one
door, since other doors were locked or it was impossible
or difficult to access the door and the exit route. Also, in
a study in a Social Security hospital of Khorramabad city,
Malekshahi and Mardani[12] explained that 90% sections of
this hospital had only one entrance and exit door, and in
10% remaining sections, the doors were locked. In case of
emergency cases for evacuation in a disaster, the patients
and staff need minimum 10 minutes to reach the open area.
On the other hand, hospital doors and windows were not
strong enough and therefore needed to be painted and
lubricated. Meanwhile, an assessment in children’s hospital
in Skopje showed that glasses are the most dangerous
elements in hospital building and use of window‑panes near
the partitions and separators could be very dangerous.[8]
Also in the current study, doors and windows lacked the
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Jahangiri, et al.: HSI analysis in confronting disasters: A case study from Iran
proper strength and in case the glasses were broken due to
earthquake, there was the probability of dangers resulting
from the shooting of glass bits. Therefore, it is recommended
to cover glasses of windows and partitions, especially in
crucial areas such as emergency and intensive care unit with
a window firm to decrease the danger of shooting glasses
during earthquakes.
In the 1994 Northridge California earthquake, electricity
cut was the main cause of patients’ evacuation in
14  hospitals.,[13] In the current study, required electricity
of the hospital was provided by the public network and
electric generator provided 100% electricity of hospital in
case of its cut. Moreover, another energy providing source
should be considered for lighting special parts of hospital
such as emergency care, and operation room during the
electricity cut.
For providing the required water in case of disaster
occurrence, the case study hospital had two sources
of ground water, each had 12,000 liter capacity. After
evaluating the water system of another hospital in Tehran
named Shahid Labafi hospital, it was revealed that the
main water consumption is from urban water source with
a 80000 liter storing water reservoir and a smaller reservoir
for the hospital dialyze section.
In Skopje children’s hospital, it was shown that medical
gases from the central medical unit were accessible via
plumbing network.[8] In evaluating medical gases status,
in the current study, the medical gas is the gas capsule.
Hospital had 44 capsules, capacity 40 liter, 30 capsules,
capacity 20 liter and 20 capsules with capacity of 10 liter.
In various sections, there were 20 and 10 liter capsules
and for providing the central oxygen capsule, the 40 liter
capsules were used. Storing these capsules was allowed
for only three days.
Moreover, the under study hospital communication
system was not satisfactory and the only communication
tools of hospital was telephone and pager. Also, a
replacing location for communication center has not been
considered and controlling system for the equipment and
communication cables was not suitable. Shojaie in a similar
survey relevant to evaluating different systems in under
studied hospitals stated that a few of them have telephone,
pager and wireless and other ones do not have wireless
and only have telephone and pager and communication
system in this hospital is not suitable.[11] In evaluating fire
extinguishing system, it can be noted that, in all parts of
under study hospital, detectors were installed, but they
were inactive. In this hospital, sprinkler fire system  (an
automatic system) was not used. A fire sprinkler system
is an active fire protection, consisting of a water supply
system, providing adequate pressure and flow rate to a
water distribution piping system, on which fire sprinklers
are connected. Therefore, it is suggested to use it in some
parts such as kitchen, warehouse and laboratory in which
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the probability of fire accident risk is high. Fire fight
capsules have also been installed in all parts and sections
of the hospital’s walls vertically. But these capsules were
sizeable and heavy and it was not possible to be used
by women in the case of an accident. Therefore, it is
recommended to use smaller capsules.
The under study hospital heating system was radiator and
the cooling system was chiller. Air conditioning system
of all parts of mentioned hospital was air ventilation,
which does not function properly in some sections of the
hospital such as clinic and care units and therefore, more
strong conditioning system should be installed. The engine
house of this hospital was old and poorly operated. Pipes,
connections and valves of engine room are continually being
repaired and renovated. Engine room and its equipment
should be fundamentally repaired. In a similar study,
Amini Ghazvini[14] declared that the heating, cooling and
air conditioning system of a private hospital in Tehran
needs to be installed better and should be fasten to the
ceiling or the wall. In the current case study, the hospital
functional (managerial) vulnerability is almost moderate.
The majority of problems in this hospital were relevant to
the functional (managerial) issues, related to the lack of
financial sources and suitable non‑programming source
management. Amini Ghazvini in his study stated that
although source applicability was at a desirable level, but
there was no program for source management in emergency
conditions.
Hospitals are highly complex facilities, which provides
health care as well as functions as a hotel (inpatients),
an office building (medical staff and administration),
a laboratory and a warehouse. Hospitals have a high level
of occupancy (patients, medical and support staff, visitors)
including expensive medical equipment. As mentioned,
although hospitals are essential for dealing with disasters,
their complexity, occupancy level and specific equipment
and installation system also make them vulnerable
in various aspects: structural (load bearing system),
nonstructural (architectural elements, installation and
equipment) and administrative  (organization of function
space, staff, procedures, etc).
It is evident that emergencies require an increase in treatment
capacity, and a hospital must be ready for optimal use of its
existing resources. A hospital must also ensure that trained
personnel are available to provide high quality, compassionate,
and suitable treatment for those injured in a disaster. Given
the importance of an efficient response to emergencies and
the need for a functional health care infrastructure in the
aftermath of a disaster, hospital administrators must consider
all aspects of the  hospital vulnerability. In areas prone to
seismic activity, both existing and planned hospitals must
comply with the seismic design codes. These are intended
to ensure the safety of buildings’ occupants and to allow
facilities to stay functional during and after the earthquakes.
Various methods for assessing the vulnerability of a hospital
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Jahangiri, et al.: HSI analysis in confronting disasters: A case study from Iran
exist, which differ in cost, complexity and precision. In this
paper, with regard to the obtained HSI, the under examined
hospital is categorized in classification “C” mentioned in
methodology section, which means that the vulnerability
level of this hospital is high. This is a central hospital where
resident’s life and safety are exposed to danger during and
after a disaster. Therefore, interventional urgent actions are
needed in order to decrease the expected harm and danger
due to probable future earthquakes.
Acknowledgment
Hereby, the authors would like to thank the respected
authorities in Social Security Organization, Tehran branch,
especially the assistance of Mr. Rezaie. With regard to the
ethical standards, some information related to the under
examined hospital including its name and detailed findings
are kept confidential by the researchers, as requested.
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How to cite this article: Jahangiri K, Izadkhah YO, Lari A. Hospital
safety index (HSI) analysis in confronting disasters: A case study
from Iran. Int J Health Syst Disaster Manage 2014;2:44-9.
Source of Support: Nil, Conflict of Interest: None declared.
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