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1
Centre for Emergency and
Disaster Management, School
of Public Health and Social
Work, Queensland University of
Technology, Brisbane, Australia
2
School of Nursing, Shandong
University, Jinan, Shandong
Province, P. R. China
Correspondence to
Prof. Gerry Fitzgerald, Centre
for Emergency and Disaster
Management, School of Public
Health and Social Work,
Queensland University of
Technology, Victoria Park
Road, Kelvin Grove, QLD 4059,
Australia;
gj.fitzgerald@qut.edu.au
Received 18 December 2012
Revised 18 June 2013
Accepted 6 August 2013
Published Online First
12 September 2013
To cite: Zhong S, Clark M,
Hou X-Y, et al. Emerg Med J
2014;31:930–938.
930
Development of hospital disaster resilience:
conceptual framework and potential measurement
Shuang Zhong,1 Michele Clark,1 Xiang-Yu Hou,1 Yu-Li Zang,2 Gerard Fitzgerald1
ABSTRACT
Objective Despite ‘hospital resilience’ gaining
prominence in recent years, it remains poorly defined.
This article aims to define hospital resilience, build a
preliminary conceptual framework and highlight possible
approaches to measurement.
Methods Searches were conducted of the commonly
used health databases to identify relevant literature and
reports. Search terms included ‘resilience and framework
or model’ or ‘evaluation or assess or measure and
hospital and disaster or emergency or mass casualty and
resilience or capacity or preparedness or response or
safety’. Articles were retrieved that focussed on disaster
resilience frameworks and the evaluation of various
hospital capacities.
Result A total of 1480 potentially eligible publications
were retrieved initially but the final analysis was
conducted on 47 articles, which appeared to contribute
to the study objectives. Four disaster resilience
frameworks and 11 evaluation instruments of hospital
disaster capacity were included.
Discussion and conclusion Hospital resilience is a
comprehensive concept derived from existing disaster
resilience frameworks. It has four key domains: hospital
safety; disaster preparedness and resources; continuity of
essential medical services; recovery and adaptation.
These domains were categorised according to four
criteria, namely, robustness, redundancy, resourcefulness
and rapidity. A conceptual understanding of hospital
resilience is essential for an intellectual basis for an
integrated approach to system development. This article
(1) defines hospital resilience; (2) constructs conceptual
framework (including key domains); (3) proposes
comprehensive measures for possible inclusion in an
evaluation instrument; and (4) develops a matrix of
critical issues to enhance hospital resilience to cope with
future disasters.
INTRODUCTION
In recent times, the concept of disaster resilience has
gained importance in the light of the increased fre-
quency and impact of disasters, including natural
disasters, pandemics and terrorism.1 The notion of
resilience can encompass the qualities that enable
the individual, organisation or community to resist,
respond to and recover from the impact of disas-
ters.2 Healthcare resilience, especially hospital resili-
ence, is essential as it provides ‘lifeline’ services for
minimising the impact of disasters on the commu-
nity and achieving higher community resilience.1 3–5
There are still a few studies that have focused on
hospital resilience. Instead, considerable work has
been undertaken aimed at defining hospital capacity
to cope with disasters from different perspectives
using various concepts, such as hospital safety,
Zhong S, et al. Emerg Med J 2014;31:930–938. doi:10.1136/emermed-2012-202282
hospital preparedness, hospital business continuity
and surge capacity. Additionally, international orga-
nisations such as WHO and PAHO, and countries
such as the USA, have developed specific tools and
specific measures mainly to evaluate hospital disas-
ter preparedness and hospital safety.4 6–15 However,
these disaster concepts occur in isolation, provide
limited perspectives of disaster capacity and result in
gaps, and, at times, duplication.16 For instance,
there was a great deal of overlap but little consist-
ency in what constitutes ‘hospital preparedness’ or
how it should be measured. Most hospital prepared-
ness studies have focussed on a full range of manage-
ment activities, not just those designed to enable
responses to events. The preparedness documents
reviewed rely nearly exclusively on structural mea-
sures (eg, human, equipment), but have little
concern for hospital infrastructural safety and emer-
gency services, which are linked to the hospital’s
ability to cope with disasters.16 17 There is little con-
sensus regarding which measures should be selected
and how to integrate these measures into a compre-
hensive framework for measuring core hospital cap-
acity. Thus, developing the concept of ‘hospital
resilience’ would provide a starting point for broad
agreement about what comprises hospital core cap-
acity and assist in integrating this capacity into a
comprehensive whole view.
Given the critical role of hospitals, the model of
‘safe and resilient hospitals’ was promoted as a key
component of disaster risk reduction planning in
the healthcare sector during the 2005 World
Conference on Disaster Reduction.18 19 This con-
ference endorsed policies that ensure ‘that all new
hospitals are built with a level of resilience that
strengthens their capacity to remain functional in
disaster situations’.18 19 To improve hospital resili-
ence for disasters, it is essential to clearly define the
concept and to identify its key domains.
There is some imperative for devising a user-
friendly assessment instrument for hospital resili-
ence that can maximise the concept development.
Such an instrument could be used to better under-
stand the full extent of hospital resilience and also
as a decision-support tool for promoting strategies
and policies aimed at improving hospital resilience.
To date, there are few studies that have identified
the key domains of hospital resilience, let alone
developed an assessment instrument.
This article aims to build a conceptual framework
from the literature, which identifies the key domains
of hospital resilience so as to highlight issues that
could be used for measurement and improvement.
The study has four objectives (1) it defines hospital
resilience; (2) it constructs a conceptual framework
(including key domains); (3) it proposes measures
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for possible inclusion in an evaluation instrument; and (4) it
develops a matrix of critical issues to enhance hospital resilience
to cope with future disasters.
METHODS
Major health electronic databases including ProQuest, EBSCO,
Web of Science, PubMed and ScienceDirect were searched to
retrieve relevant publications, including reports, grey literature
and published articles that may be applicable to research aims
and objectives. Two sets of search terms were used, namely,
(1) ‘resilience and framework or model’ or (2) ‘evaluation or
assess or measure and hospital and disaster or emergency or
mass casualty and resilience or capacity or preparedness or
response or safety’. Additional references were identified
through examination of the references from most recent publi-
cations (snowballing) and through scrutinising the contents
pages of highly relevant journals from the last 2 years.
Inclusion criteria were: (1) journal articles, reports and grey
literature written in English; (2) within the first search strategy,
studies that include disaster resilience frameworks, models or
key domains; and (3) within the second search strategy, studies
that identify instruments and associated measures for assessing
aspects of hospital disaster capacity.
Exclusion criteria were: (1) within the first search strategy,
studies that only focused on individual resilience, staff resilience
and resilience engineering without relevance to hospital resili-
ence; and (2) within the second search strategy, studies without
any evaluation instruments that could assist to inform the identi-
fication of measures to evaluate hospital disaster capacity.
The titles and abstracts of articles were reviewed by the princi-
pal researcher (SZ) for relevance and significance and the full
text of articles retrieved when appropriate. Full-text articles were
analysed for their contribution to the definition, conceptual
understanding of resilience, identification of the domains of hos-
pital resilience and possible evaluation measures. Publications,
including public reports, grey literature and journal articles
written in English were included in this review, spanning the
years 1981 to Feb 2013. A widely accepted measurement defin-
ition has been used in this study.17 20 The term ‘measure’ includes
a statement about the existence or performance of healthcare
that is deemed to contribute to hospital resilience under relevant
domains and subdomains. An instrument is a collection of these
measures.
This article covers all four objectives around a logical core.
First, evidence that contributed to the concept and definition of
hospital disaster resilience was identified. Second, existing fra-
meworks from other sectors and their underpinning domains
were identified and evaluated for their applicability to the
health sector. From this analysis, a draft conceptual framework
was developed for further testing and evaluation. Finally, evi-
dence of resilience measures was sought along with instruments
of hospital capacity in the context of disasters (eg, hospital
safety, hospital disaster management).
Two reviewers assessed the suitability of these measures based
on each measure’s relevance to the hospital resilience concept,
which includes hospital structural components, non-structural
components, emergency medical functions and disaster manage-
ment. In cases of substantial disagreement between the reviewers,
the potential measures were still included in the framework for
further experts’ discussion. Such an approach aims to minimise
the chances of missing or rejecting a relevant measure. Measures
need to be included in at least one instrument, with perceived
relevance to the definition of hospital resilience or its measure-
ment. The purpose of this extraction was to allow documentation
Zhong S, et al. Emerg Med J 2014;31:930–938. doi:10.1136/emermed-2012-202282
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of measurement domains for hospital disaster resilience, which is
a foundation for future evaluation.
RESULT
A total of 1480 potentially eligible publications were retrieved
initially. Of these 1193 were excluded through screening the title
and then the abstract. After scanning the full text of the remain-
ing 287 publications, the final analysis was conducted on 47 arti-
cles, which appeared to contribute to the study objectives.
As hospital resilience is a relatively new concept and focus of
attention, there is still no agreed conceptual framework for its
usage. There are existing disaster resilience frameworks of non-
hospital sectors, such as communities or organisations. We
reviewed these frameworks as a basis for a better understanding
of the disaster resilience domains. However, we have not
included frameworks that do not appear to have significance for
the health sector in this document. For instance, many publica-
tions were not included that devised frameworks or models
using sophisticated mathematical modelling and calculations,
which came largely from a resilience engineering paradigm.
Four relevant disaster resilience frameworks, which focus on
community disaster resilience and organisation resilience, were
selected.1 21–23 The selected frameworks were user-friendly and
interpretable at the lay level with a description of key domains
or criteria for disaster resilience that can be adapted into the
hospital resilience context. The disaster resilience frameworks
are described in the discussion section.
Evidence of resilience measures was sought along with instru-
ments for measuring hospital capacity in the context of disasters
(eg, hospital safety, hospital disaster preparedness). Research
sourced for the second search strategy was expected to be used
to synthesise potential measures that could be used for evaluat-
ing hospital resilience and for highlighting critical issues to
enhance hospital resilience. A total of 11 studies were located,
which focussed on instruments that evaluated hospital disaster
capacity (eight peer reviewed articles and three public reports).
Each of the 11 studies contains an instrument with associated
measures for assessing aspects of hospital capacity in responding
to disasters.4 6–15 Table 1 displays the data and categories
extracted from each instrument.24 25 Most studies (n=7)
focused on hospital preparedness for disasters, and on hospitals’
response and recovery capability and surge capacity. Other
studies evaluated hospital safety to disasters (n=2) or else
focused on hospital linkages with the community during disas-
ters (n=2). It is noteworthy that a large number of the studies
were based on US experiences post 9/11. Common limitations
of these studies included a focus on specific disasters rather than
all hazards, lack of reliability and validity, lack of scoring proce-
dures or self-report without further verification.
There are also several challenges derived from measures of
these instruments. First, one of the characteristics of good mea-
sures is that they encode clear standards with the data elements
explicitly detailed.26 Many of the measures in the evaluation
instruments were subjective in the form of checklists or ques-
tionnaires. For example, measures of timely reporting of key dis-
eases often failed to specify thresholds for timeliness and
completeness or whether those thresholds varied by the report-
able conditions. These issues of clarity preclude a description of
the validity of identified measures, which was also lacking in the
identified instruments. Second, ideal measurement systems span
the Donabedian categories of structure (capacity), process
(service) and outcomes.27 28 Structure measures are the human,
physical and financial resources available to provide healthcare.
Process measures describe the care or emergency health service
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Data extraction and evaluation of hospital assessment instruments to disasters4 6–15

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Table 1
Instrument Hospital Hospital Hospital disaster Hospital Emergency AHRQ–HRSA pilot Emergency Mass Casualty Hospital public WHO hospital PAHO safe WHO safe hospitals
name integration into bioterrorism preparedness Readiness Overview hospital response Disaster Plan health emergency response checklist hospital index in emergencies and
community preparedness (HERO) survey preparedness preparedness Checklist preparedness disasters
preparedness linkages with the assessment tool national survey
community
Author(s) Braun et al, 2006 Braun et al, 2004 Kaji, 2006 Kollek, Cwinn, 2011 Thorne et al, 2006 Niska, Shimizu, Higgins et al, 2004 Li et al, 2008 WHO report, 2011 PAHO report, WHO report, 2010
2011 2008
Disaster type All-hazards Bioterrorism All-hazards Chemical, biological, Bioterrorism All-hazards Mass casualty All-hazards All-hazards All-hazards All-hazards
radiological or preparedness event
nuclear
Purpose Evaluate hospital Evaluate hospital Measures of Assess hospital Assess the hospital Evaluated hospital Assess Assess the statues An all-hazards tool Evaluate Assess hospital
community linkages with hospital disaster chemical, biological, preparedness, preparedness and preparedness for of hospital public for hospital hospital structural,
services linkages community for preparedness and radiological or response and surge emergency mass casualty health emergency administrators safety from non-structural and
for response bioterrorism surge capacity nuclear readiness capacity response events in hospitals preparedness priority response disasters functional
actions vulnerabilities
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Type of tool Questionnaire Questionnaire with Survey and on-site Online survey Questionnaire Questionnaire Questionnaire Questionnaire Checklist Checklist Checklist
on-site verification verify
Dimensions 4 (17) 4 (51) 6 (117) 5 (48) 6 (38) 6 (112) 4 (252) 17 (192) 9 (92) 4 (143) 3 (69)
(measures)
Scaling Yes/No Yes/No and Yes/No Yes/No/do not know Fixed-choice Yes/No Yes/No Yes/No/do not Due for review/in low/average/ Yes/No
open-ended items and multiple-choice questions and know progress/completed high
items open-ended
questions
Scoring N/A N/A N/A N/A N/A N/A Yes Yes N/A Yes N/A
Reliability Internal Not tested Not tested Not tested Not tested Not tested Internal Not tested Not tested Not tested Not tested
consistency consistency,
intercorrelation
Validity Face validity was Not tested Not tested Not tested Not tested Not tested Not tested Face and content Not tested Not tested Not tested
tested validities
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provided to the patient. Outcome measures are the resulting
effect on the health of the patient or population.27 28 However,
the preparedness documents reviewed rely nearly exclusively on
structural measures (eg, human resources, plans, equipment)
over process (emergency service) and outcome.
DISCUSSION
Defining hospital resilience
Hospital resilience is a comprehensive concept that includes
structural components (eg, facility safety), non-structural com-
ponents (eg, staff, medication and equipment), emergency
medical functions (eg, continuity of medical service) and disaster
management capacity (eg, plan and procedure, crisis communi-
cation, community linkage).29 In order to be resilient, hospitals
need to withstand the event, with both inherent strength (ability
to resist and respond to an external shock) and adaptive flexibil-
ity (ability to bounce back and adapt). At the same time they are
expected to be able to provide emergency medical services and
surge their capacity to respond to sudden increases in demand
associated with disasters.30–32
Hospital disaster resilience can be comprehensively defined as
‘hospital’s capability to resist, absorb, respond to the shock of
disasters while still retaining their most essential functionality
(eg, prehospital care, emergency medical treatment, critical care,
decontamination and isolation), then recover to its original state
or a new adaptive state.’1–3 33 34 More specifically, ‘hospital
resilience is the capability to absorb the impact of disasters
without loss of functions (termed resistance); maintain its most
essential functions (called absorption and responsiveness); and
‘bounce back’ to the pre-event state (termed recovery) or to a
new state of function (termed adaptation).’ These capacities are
achieved through a wide variety of measures and strategies.35
Development of hospital resilience conceptual framework
In the absence of any existing framework, domains drawn from
other sectors, such as community or organisation resilience may
have applicability to health services and may help inform a hos-
pital resilience framework. These frameworks are discussed
below and used for development of a conceptual framework for
hospital resilience.
An Australian government disaster resilience model was devel-
oped by undertaking a thematic analysis of the community
Figure 1 Understanding hospital
disaster resilience criteria (adapted by
the authors, from Bruneau et al 2003).
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resilience literature. Its four domains are community connected-
ness; risk and vulnerability; planning and procedures; and avail-
able resources. These domains overlap and interact, making
relatively equal contributions to building community resili-
ence.21 Healthcare resiliency sits at the centre of several inte-
grated domains, including emergency management, risk
management, safety/security, business continuity, disaster recov-
ery and crisis communications.22 One organisational resilience
report concluded that the concept of ‘adaptive capacity’ is an
essential part of resilience.23 Adaptive capacity is defined as the
ability of an organisation to alter its strategy, operations, man-
agement systems, leadership structure and decision-support cap-
acity to withstand disasters, generally by adopting adaptive
qualities and proactive responses.23
Arguably one of the most used resilience frameworks is the
MCEER’s framework. It has been used recently to describe com-
munity and organisational resilience in the context of seismic
risks.1 33 36–38 The framework includes four criteria, two of
which, robustness and rapidity are seen as ‘ends’, and two of
which, resourcefulness and redundancy, are seen as ‘means’. The
model integrates these criteria into four domains of community
resilience.1 All of these criteria can be used to examine disaster
resilience for various types of physical and organisational
systems,1 33 36 39 such as healthcare systems and hospitals.33 36 40
Figure 1 can be used to better understand the relevance of
these resilience criteria to hospital disaster resilience. The extent
of a hospital’s resilience can be measured with reference to the
level of hospital function, such as the number or percentage of
patients assessed and treated. The horizontal line showing full
hospital operation is fixed, implying a single optimum. The
occurrence of a disaster leads to a rapid decrease in function
performance. The extent to which the function is maintained
reflects the hospital’s robustness. Over time, the hospital regains
some level of equilibrium. The speed with which this recovery
of function is achieved reflects the hospital’s responsiveness
(rapidity). Robustness and rapidity can be improved by both pre-
paredness and responsiveness activities.36
It would appear timely to establish a new conceptual frame-
work by adapting relevant resilience frameworks to a hospital
resilience context. Existing resilience frameworks are not
hospital-focused. This may limit the extent to which existing
frameworks can be directly applied to complex entities such as
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hospitals, although, it is anticipated that there may be some
domains of these frameworks that may have relevance to a hos-
pital setting.
We have adapted the disaster resilience domains for hospital
resilience. The initial key domains were aggregated to incorpor-
ate all the hospital’s key capacities to cope with disasters, includ-
ing hospital safety (surveillance, safety/security), hospital disaster
preparedness and resources (disaster planning and procedure,
crisis communications, community connectedness, available
resources and logistics management), continuity of essential
medical services (emergency medicine, medical continuity and
surge capacity), recovery and adaptation (recovery, evaluation
and adaptation).21 22
The MCEER’s framework includes four criteria of disaster
resilience, including robustness, resourcefulness, redundancy
and rapidity. These criteria can be integrated into the four
domains of hospital resilience via a conceptual framework illu-
strated as figure 2.
It has been developed to provide a holistic interpretation of
our understanding of hospital resilience. Within this conceptual
framework, hospital resilience can be assessed by robustness,
redundancy, resourcefulness and rapidity, which is in-turn, influ-
enced by a complex of various adapted resilience domains. This
new framework links key domains and hospital management
approaches with an achievable goal of improving hospital
pre-event robustness and promoting rapid response and recov-
ery.41–44 It is hoped that the ethos of hospital resilience may be
consistent with, and contribute to, integration of the core cap-
acity into a comprehensive hospital disaster management frame-
work.22 It is essential to put hospital disaster capacity,
management activities and disaster outcomes together into a
comprehensive whole view using an integrated approach.
Developing the conceptual framework of ‘hospital resilience’
would provide a starting point for broad agreement about what
Figure 2 Conceptual framework of
hospital and healthcare resilience
(developed by the authors).
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comprises hospital core capacity in the context of disasters, and
would also assist in integrating this broad range of capacities
together into a comprehensive whole view. By adapting the key
domains into the hospital context, it is hoped that this new con-
ceptual framework for health will be consistent with an all agen-
cies approach, and an approach that promotes the integration of
hospitals within the community.
Measuring hospital resilience
The preliminary conceptual framework of hospital resilience
can be used as a foundation to further develop an instrument
with potential measures for evaluation. While recently some
work (eg, preparedness, response capability, surge capacity) has
been done on hospital capacity to cope with disasters, these
current studies have added to the body of knowledge as it is the
first time that a conceptual framework has been developed for
disaster resilience and that the work will enable hospitals to
examine their level of resilience. This is the first time that the
literature has been examined from a holistic perspective in order
to draw the diverse measures into a coherent whole.
The search extended to hospital disaster studies (eg, hospital
safety, hospital disaster preparedness, response capability, surge
capacity) and sought to describe the possible domains of the
framework, and provide measures for further evaluating hospital
resilience. All selected studies illustrated in table 1 focus on the
evaluation of hospital capacity to cope with disasters. Although
the foci of these studies were different and not all their compo-
nent parts are directly comparable, a number of domains were
identified. Within each domain, we classified subdomains. For
example, within hospital safety, we identified disease surveil-
lance, hospital safety and vulnerability as subdomains.
The purpose of this classification was to allow documentation
of measurement domains and comparisons of the scope of the
instruments. The authors discussed the relevant subdomains and
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Table 2 Measuring framework of hospital resilience (extracted from the included studies)4
Domains Subdomains
1. Hospital safety and 1.1 Disease surveillance
vulnerability
1.2 Hospital risk and safety
2. Disaster preparedness 2.1 Emergency leadership
and resources 2.2 Community cooperation and
communication
2.3 Disaster plans
2.4 Disaster stockpiles and
logistics management
2.5 Emergency staff
2.6 Emergency trainings and
drills
3. Continuity of essential 3.1 Emergency medicine
services 3.2 Surge capacity
4. Recovery and adaptation 4.1 Recovery capability
4.2 Evaluation and adaptation
achieved agreement on the extracted main subdomains, namely,
hospital internal safety, disease surveillance, emergency leader-
ship, disaster plan, community linkage, crisis communications,
emergency staff, available resources and logistics management,
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6–15
Measures
1.1.1 The surveillance procedures (eg, abnormity in admission diagnosis, routine microbiological tests,
surveillance of emergency room patients and death with unknown causes)
1.1.2 The surveillance report and information sharing policy
1.2.1 The building code and locations of hospital critical infrastructures to meet of high risks (eg,
earthquake, fire safety, flood, typhoon)
1.2.2 The safety and security issues of architectural components (eg, ceilings, windows, doors, medical
and laboratory equipment, mechanical, electrical and plumbing installations).
1.2.3 The assessment strategise for hospital vulnerability and risks
1.2.4 The strategy to evacuate and protect existing patients
1.2.5 The alternative emergency energy and facilities for backup (eg, power, water, oxygen and
telecommunication)
1.2.6 Area for radioactive, biological and chemical decontamination and isolation
2.1.1 The emergency committee or commend centre (eg, workplace, communication equipment and staff)
2.2.1 The crisis communication within hospital
2.2.2 The communication and cooperation with other community facilities (eg, hospital facilities,
government offices, media and public utilities)
2.3.1 Plans for different kinds of disasters
2.3.2 The period of evaluating and revising the plan
2.3.3 Hospital plans are involved within community-wide plan
2.3.4 The rapidity for staff, equipment can be in place when initiating the plan
2.3.5 Emergency standard operating procedures to execute the plan (eg, procedures to activate and
deactivate the plan)
2.4.1 The stock quantity of different emergency supplies
2.4.2 The strategies for management of emergency supplies (eg, logistics and distribution, contracts with
suppliers and other hospitals, adjusted standards for their usage)
2.4.3 The stock quantity of essential medicines for various disasters
2.4.4 The strategies for management of medicine (eg, drug-distribution and management plans, priorities
limited drugs for critical departments and patients)
2.5.1 The emergency staff and expert group (eg, quantity, qualification, speciality, experience)
2.5.2 The protective and incentive strategies for key staff (eg, staff role reassignment, staff incentives,
insurance, immunisation, living requirements, care for families, psychosocial support)
2.5.3 The key staff knowledge of disaster management (eg, the role in disasters, the local emergency
response system and emergency plans for disasters)
2.5.4 The key staff skills of disaster treatment (eg, medical first aid, isolation, decontamination and triage
procedures)
2.6.1 Different incident types for trainings/drills
2.6.2 The period for the last training/drills
2.6.3 The percentage of staff for training/drill
2.6.4 The contents of trainings (eg, triage, emergency treatment, training of volunteers)
2.6.5 The methods for implementing drills (eg, desktop drill, community-wide drill)
2.6.6 Evaluation of emergency simulation exercise or drill
3.1.1 The procedures to identify, prioritise and maintain essential functions (eg, cancellation of elective
admissions, early discharge of patients, making new medical quality standard during disasters, extra
protection for vulnerable population)
3.1.2 Mass-casualty triage protocol based on severity of illness/injury, survivability and hospital capacity
3.1.3 The quantity of equipment for on-site rescue (eg, ambulance, helicopter, communication equipment)
3.1.4 The types and quantity of hospital emergency equipment (eg, for medical treatment,
decontamination and personal protection)
3.1.5 Procedures for referral and counter-referral of patients
3.2.1 The proportion of surge capacity of emergency space (eg, emergency beds, ICU, isolation rooms)
within a limited period
3.2.2 The proportion of surge capacity of emergency equipment, medication and resource within a limited
period
3.2.3 The proportion of surge capacity of hospital staff within a limited period
3.2.4 The rapidity of surge emergency space, resource and staff
3.2.5 The strategies for surging inpatient capacity (taking physical space, staff, supplies and processes into
consideration)
3.2.6 The strategies for surging key staff (eg, transfer from non-critical departments and other hospitals,
volunteers)
4.1.1 The rapidity for hospital recovery of its critical function
4.1.2 The strategies for community short-term recovery
4.1.3 The strategies for community long-term recovery (eg, mental counselling, chronic disease
management, family support)
4.2.1 The evaluation and adaptation report (eg, incident summary, response assessment, vulnerability
analysis and risks reassessment)
4.2.2 The strategies for hospital adaptation based on the evaluation
disaster trainings and drills, emergency response, medical treat-
ment, surge capacity and hospital disaster recovery and adapta-
tion. The priori hypothesis has been approved that the extracted
key domains or particular subdomains be consistent with
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preliminary recognised domains of hospital resilience. All
domains and subdomains were addressed by at least one evalu-
ation instrument. The measures were also extracted and synthe-
sised within these subdomains. These measures are relevant to
the concept of hospital resilience and at least one of basic resili-
ence criteria including robustness, resourcefulness, redundancy
and rapidity.1 33–38 Similar measures across papers were merged
in order to ensure key measures, which captures similar mean-
ings from different papers.45 46
Through extracting and synthesising measures, a comprehen-
sive framework was constructed for documentation of the meas-
urement domains of hospital resilience, which integrate
potential measures for future development of an evaluation
instrument. There are four primary domains, 12 subdomains
and 46 potential measures illustrated in table 2.
The domains and subdomains included hospital safety and
vulnerability (surveillance, hospital internal safety); hospital dis-
aster preparedness and resources (emergency leadership, com-
munity cooperation and crisis communication, disaster plans,
disaster stockpiles and logistics management, emergency staff,
emergency trainings and drills); continuity of essential medical
service (emergency response, emergency medicine, emergency
surge capacity);and recovery and adaptation (recovery, evalu-
ation and adaptation). Recognition of an evaluation framework
provides a foundation for a more comprehensive instrument for
measuring a hospital’s resilience. This instrument could be con-
verted to a self-assessment questionnaire, using dichotomous
indicators, multisection indicators or quantitative indicators.
Alternatively, it could be developed as a scorecard or checklist.
Critical issues for enhancing hospital resilience
Table 3 is a comprehensive matrix of hospital resilience with
potential measures adapted from the conceptual framework. All
measures are categorised to various domains of the conceptual
framework for a higher level of interpretation and better under-
standing of the concept.
Robustness describes a hospital’s inherent strength to with-
stand the consequences of an event. Redundancy is achieved
through backup and surge capacity of staff, infrastructure,
resources and equipment. Resourcefulness is an adaptive flexibil-
ity for maintaining hospital essential services. Rapidity reflects
the speed of hospital responsiveness through fixing things up,
bouncing back, functional recovery and adaptation. All the iden-
tified hospital resilience measures are included in one of the
four basic resilience criteria.1 This matrix can be used to guide
the operationalisation of the concept of hospital resilience, and
for identifying critical issues for enhancing hospital resilience in
disasters. It is noted that table 3 is only used for illustration, and
needs to be further developed.
Strengths and weaknesses
This is the first step in a comprehensive body of work designed
to develop a conceptual framework for understanding hospital
resilience and its domains, and to identify possible measures.
This first step is to draft a working draft model with a view to
seeking expert commentary. This will be done as part of the
research project, but we also believe that this will be enriched
by broader professional commentary beyond that of the research
as would result from discussion of the draft. We have attempted
to adapt conceptual frameworks from other sectors as a basis
for a better understanding of the disaster resilience domains.
However, we have not included frameworks that do not appear
to have significance for the health sector in this document. This
adapted framework is expected to be consistent with an ‘all
agencies’ approach, which promotes integration of hospitals
within the community. But the new framework does need to
adapt ‘non-health’ frameworks as direct translation is likely to
be inappropriate, and there is little validation of those frame-
works even in the principal areas of their focus.
Measures were also identified on the grounds that these
describe the domains of the framework and provide a means of
further evaluating hospital resilience. The candidate measures
may form a suitable measurement tool for evaluating hospital

Table 3 Proposed metric of hospital resilience: critical issues for enhancing hospital disaster resilience
Performance criteria
Domains Robustness Redundancy Resourcefulness Rapidity

Hospital resilience illustrative measures*

Hospital safety (surveillance, safety) ▸ Surveillance procedures
▸ The building code of
infrastructures
▸ Areas for isolation
Disaster resource and preparedness (Leadership, ▸ Emergency committee
communication and cooperation, plans, ▸ The quantity of
emergency resource, staff, training and drills) emergency supplies and
essential medicines
▸ Key staff disaster
management skills
Continuity of essential medical service ▸ The types and quantity
(emergency medicine, surge capacity) of equipment for
emergency medicine
▸ The triage protocols
Recovery and adaptation ▸ Recovery strategies
▸ Evaluation report
*Source: Adapted by the authors, from community disaster resilience, Bruneau et al, 2003.1
▸ The alternative emergency ▸ The assessment strategies
energy for hospital vulnerability
▸ Facilities for backup and risks
▸ The strategy to evacuate
and protect existing patients
▸ Training of backup non-ED ▸ Plans for different disasters
personnel and volunteers ▸ Logistic management for
for emergency supplies, medicine
▸ The cooperation with other ▸ Key staff administration
facilities for backup ▸ Various incident types for
resources trainings and drills
▸ Methods for implementing
drills
▸ The proportion of surge ▸ Strategies for surge
capacity of beds, space, inpatient capacity
resources and key staff ▸ Strategies to identify,
prioritise and maintain
essential functions
▸ Extra hospital staff for ▸ Strategies for recovery
community demands ▸ Strategies for adaptation
▸ The rapidity for risk
assessment
▸ The rapidity for
evacuation
▸ The rapidity for the crisis
communication
▸ The rapidity for reassign
the staff roles
▸ The rapidity to response
to the plan
▸ The period for the last
training/drill
▸ The rapidity for surging
emergency space,
resources and staff
▸ The rapidity for on-site
rescue
▸ The rapidity for hospital
recovery and adaptation

936 Zhong S, et al. Emerg Med J 2014;31:930–938. doi:10.1136/emermed-2012-202282

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resilience, and for measuring the impact of improvement strat-
egies. However, before they can be used for empirical studies,
reliable measures need to be selected, modified or validated
further. The additional consideration by experts is needed for
its development to a user-friendly instrument. The measures in
the framework were still in the form of checklists without clear
evaluation standards or benchmarks. This is because the extant
evidence base is insufficient to determine either the capacity or
the process measures that are linked to desirable outcomes or
the levels of those measures that would be regarded as
adequate.17 In the future, empirical outcomes from hospital
surveys are also needed for further testing the feasibility and val-
idity of these measures, and further developing it into a meas-
urement instrument (eg, self-report questionnaire) for evaluating
hospitals in pilot areas. Then explicitly details regarding the
average or desired level of capacity or performance of the hospi-
tals in the pilot areas can be produced.
CONCLUSION
A conceptual understanding of hospital resilience is essential to
provide an intellectual basis for an integrated approach to system
development. To date there is no agreed framework for hospital
resilience that would form the basis of measurement of resilience.
This article (1) defines hospital resilience; (2) constructs a con-
ceptual framework (including key domains); (3) proposes com-
prehensive measures for possible inclusion in an evaluation
instrument; and (4) develops a matrix of critical issues to
enhance hospital resilience to cope with future disasters.
Developing the concept of ‘hospital resilience’ will provide a
starting point for agreement about what it comprises and how
to measure it. The new concept links these key components
with an achievable goal to improve hospital pre-event robustness
as well as rapidity to recover and adapt for disasters. The devel-
opment of a conceptual framework with underpinning measures
will be useful for furthering the understanding and discussion
around hospital resilience. Expert advice will add further to the
development of the framework. Future research will develop
and validate an instrument that will allow hospitals to measure
their level of resilience and thus aid in building their capacity.
Acknowledgements Thanks to the QUT–CSC joint scholarship and the
contributions of all the co-authors. This study forms part of the principal author’s
PhD research, which focuses on the definition and evaluation of hospital disaster
resilience. Further qualitative research and primary empirical data collection will seek
to test the feasibility and utility of this conceptual framework and of the measures
identified in this article.
Contributors SZ jointly designed the study, reviewed, read and analysed the
relevant literature and jointly wrote the manuscript. GF, MC, YLZ and XYH jointly
designed the study and jointly wrote the manuscript.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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Development of hospital disaster resilience:

conceptual framework and potential
measurement
Shuang Zhong, Michele Clark, Xiang-Yu Hou, Yu-Li Zang and Gerard
Fitzgerald

Emerg Med J 2014 31: 930-938 originally published online September 12,
2013
doi: 10.1136/emermed-2012-202282

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