EMForum.org Presentation — October 22, 2008

The Hospital Safety Index
Hospitals Safe from Disasters

Patricia Bittner
Program Management Officer
Area on Emergency Preparedness and Disaster Relief
Pan American Health Organization, World Health Organization

Amy Sebring
EIIP Moderator

The introduction, presentation, and closing parts of the transcript are prepared remarks and not necessarily verbatim. The Q&A portion is prepared from a transcription of the recording.

[Welcome / Introduction]

Amy Sebring: Good morning/afternoon everyone. Welcome to EMforum.org! This is a major milestone for us today as our first attempt to provide an enriched experience for you via Live Meeting. Please bear with us if there are a few kinks to be worked out.

First, our scheduling did not quite work out for observing World Disaster Reduction Day earlier this month, but today we will visit the theme of this year's campaign, "Hospitals Safe From Disasters," with specific focus on the Hospital Safety Index.

Here is the Background Page for today's session and these few links should help you find further information. [http://www.emforum.org/vforum/081022.htm]

Please note the related poll on our homepage. "Is there sufficient national emphasis on mitigation for health care facilities in the U.S.? Yes or No" Please take time to participate by voting and review the results thus far.

Please take a moment after the session to rate this session in terms of usefulness of the information and/or write a short review or post a comment. This is the one thing we ask you to do in return, and it will help visitors find relevant material in the future. It takes no time at all.

Now it is my pleasure to introduce our guest speaker for today. Patricia Bittner has worked with the Pan American Health Organization, regional office for the Americas of the World Health Organization (PAHO/WHO), for more than 20 years. Currently, she is the Program Management Officer with PAHO/WHO's Area on Emergency Preparedness and Disaster Relief, responsible for partnerships, advocacy and the management of donor grants and reporting.

In 2007-08, Pat spent an extended period working with the UN International Strategy for Disaster Reduction (Geneva) and with other WHO regional offices for Southeast Asia (New Delhi) and the Eastern Mediterranean (Cairo) to coordinate and launch the World Campaign on Disaster Reduction. Safe Hospitals will also be the theme of the 2009 World Health Day next April.

Welcome Pat and thank you for being with us today. I now turn the floor over to you to start us off please.


[Slide 1]

Patricia Bittner: If I may, I’d like to give you a very brief history of the events that led to the health sector getting serious about disaster mitigation—or, in other words, reducing the impact of disasters on health facilities.

Of the many major sudden-impact disasters in Latin America and the Caribbean in recent decades, it was perhaps the 1985 earthquake in Mexico City that served as a critical turning point – a watershed moment. Even then, Mexico City was one of the world’s largest metropolitan areas, and the 7.6 magnitude earthquake put their recently created metropolitan emergency plan to an exacting but successful test. Thanks to a well-trained workforce, Mexico’s health services responded remarkably well. They carried out evacuation plans for damaged health facilities smoothly and victims that needed treatment were redistributed throughout the metropolitan health system.

However, an important lesson was learned: that preparedness alone was not sufficient. Among the many health facilities damaged in the earthquake, the complete collapse of a wing of the Juárez Hospital was devastating. At that site alone, 561 patients, doctors and nurses lost their lives. Ironically as well as tragically, those very same health professionals had attended many PAHO-sponsored workshops and training events. They were prepared to respond to mass casualties. PAHO learned that it was simply not enough to invest in preparedness if the very hospitals and health facilities in which they worked were not safe.

It took almost another decade for these ideas to crystallize into the beginnings of a regionwide program on safe hospitals– which, since the mid 1990’s has been an important area of work in Ministries of Health throughout the Caribbean and Latin America. This decision was reinforced in 2005, when 188 countries approved the Hyogo Framework for Action –a blueprint for building disaster resilient nations—which called for all new hospitals to be built to a standard that enables them to withstand disasters and remain able to function.

[Slide 2]

Today, by and large, it is generally accepted that we can improve the safety of hospitals and health facilities in emergencies and disasters and a great deal of effort has gone into preparing technical material on building safe new hospitals or reducing vulnerability in existing ones. A massive training effort has been conducted in the Americas. Today, I’d like to talk about the latest tool that is now available—the Hospital Safety Index.

[Slide 3]

What is the Hospital Safety Index? The Hospital Safety Index is an easy-to-apply diagnostic tool that helps hospital directors or administrators determine whether or not, and the degree to which, their hospital or health facility can or will remain operational in emergency situations.

The Hospital Safety Index provides a snapshot in time of a hospital’s level of safety. The Index can be reapplied a number of times, over extended periods, in order to continuously monitor safety levels. In that way, safety is not seen as an absolute state of ‘yes-or-no' or 'all-or-nothing,’ but rather as something that can be improved gradually. It’s important to point out that the Hospital Safety Index is not meant to replace detailed vulnerability studies. However, because these can be very expensive and time consuming, the Hospital Safety Index is a cost-effective first step.

So, now that we have an overview of what the Index is and what it can realistically be expected to do, let’s take a look at the components of the Index and how it actually works.

[Slide 4]

The first component is the Safe Hospitals Checklist, which looks at the level of safety of 145 items or areas that have an impact on the safety of a hospital. These items are grouped into four categories: the hospital’s geographical location in relation to natural hazards, its structural and non-structural safety and items that affect its functional capacity—issues such as whether they have a hospital disaster committee, and emergency plan, has maintenance been performed regularly, and so on.

To give you an idea, here are sample pages from the Checklist that look at non-structural elements and functional capacity.

[Slide 5]

[Slide 6]

The Safe Hospitals Checklist is applied by a Team of Evaluators that has received prior training. The composition of the Evaluation Team can vary from country to country, but it is usually comprised of hospital staff (directors, physicians, nurses, maintenance personnel, and others) and can include outside specialists such as engineers or architects.

The Evaluation Team assesses all of the hospital areas covered in the Checklist, either together or in smaller teams. The training they receive uses a Guide for Evaluators to help them to standardize how they grade the different components of the health facility. For example, safety scores are entered onto the Checklist as low, average or high – but these can be subjective values—what may be a low level of safety to one person could be acceptable or average to another. The Guide for Evaluators provides more indepth discussion of how to evaluate objectively each component or area of the hospital.

Prior to calculating the health facility’s actual safety score, the Team meets together to discuss and agree upon the results. The final step of the process then is to calculate the safety score, using the Safety Index Calculator. Quite simply, the Calculator is an Excel spreadsheet into which the scores or values obtained for each component on the Checklist are recorded. The spreadsheet looks like the Checklist, but the cells or boxes have hidden formulas that automatically calculate a numerical score for each of the 145 components.

[Slide 7]

It is important to note that the values given to each component are weighted according to an agreed-upon formula, which has been endorsed in Latin America and the Caribbean, but may not be applicable worldwide. The result is a numerical score that places a hospital or health facility into one of three safety categories: high, medium, or low.

[Slide 8]

The results are output in an easy to understand fashion. If we look at this example, we can see that structural safety comprises 50% of the total score; non structural safety 30% and functional safety 20% and the raw scores for each of the broad areas that are assessed.

[Slide 9]

However, if we break this down further, looking at the numbers for the non-structural elements

we can see the 29% of the non-structural elements have a "high" safety rating, in other words, they are highly likely to function; the safety of 36% is considered average; and 35% are considered unlikely to function.

[Slide 10]

As you can see, the Hospital Safety Index yields an objective, numerical score. But what, exactly, can countries to do with this information?

[Slide 11]

The Evaluation Teams plays an important role. Prior to actually applying the Checklist, they must meet with hospital staff to explain the rationale and purpose of the ‘safe hospitals’ program in general and why its important to apply this diagnostic tool.

[Slide 12]

The job of the Evaluation Team is not over once the Checklist has been filled out and entered into the Scoring Calculator. It’s also their job to analyze and discuss the results and help interpret the score in terms of the next steps that a health facility can take to improve safety.

The Hospital Safety Index does not produce a detailed assessment of the sort you would get from a lengthy vulnerability assessment—but hospital administrators will get a solid overview that will help them to decide where to invest to maximize the return. Sometimes very small or low-cost improvements will go a long way toward improving safety.

[Slide 13]

It’s important that hospital and health decision makers view the safety score in a positive light – that’s why we have called this the "Safety" Index rather than the ‘Vulnerability Index.’ The final score never produces a "failing" grade but rather a starting point for gauging how a health facility is likely to respond to major emergencies and disasters.

That concludes my overview, and we can get into more detail during our Q&A, so at this point I will turn the floor back over to our Moderator to start us off.

Amy Sebring: Thank you very much Pat. Now, to proceed to your questions or comments.

[Audience Questions & Answers]

Roger Arango: Has the hospital safety index been used as a post disaster tool?

Pat Bittner: That is a very good question. The hospital safety index certainly can be used as a post disaster tool and it can also be used as a comparison if it is applied over a period of time. I know that in the most recent disasters—and this has been really coming to the forefront in the last probably year to eighteen months—and in that time the country with the most widespread experience and that has done a fantastic job in really institutionalizing this at a national level is Mexico, and they have not had any disasters that would allow them to do this.

But this is not a damage and needs assessment; it’s rather a pro-active tool. So I have not seen it applied as a comparison—in other words, applied perhaps in the beginning of 2007, and then a disaster occurs and re-applying it to measure how well we did. That, I have not seen. But I would be interested, actually, now that you say this, to see if this would serve as a diagnostic tool, too, for post disaster, but I would tend to think that it would not be quite detailed enough for that.

Wendy Marie Thomas: Thank you, Patricia for an informative talk. My question concerns the "trained teams." Is there a certification process available for teams in the U.S.?

Pat Bittner: Thanks, Wendy Marie. There has not been a great deal of distribution, either about the hospital safety index or the individual components in the U.S. yet, which is why I am very glad that we had this opportunity today to talk about this.

The certification of the evaluators (the evaluation team) is up to each individual country, and I have to say again that Mexico is the one that has gone the furthest in this. Although we have had major training sessions all over Latin America, the Caribbean, and even in other regions, and in other WHO regional offices—it’s the countries themselves.

Now Mexico does have a certification program and that’s very encouraging because they have trained over 900 evaluators in Mexico who have gone through a four-day training program and then must complete a distance-learning module on the Internet to get their certification. Now that is up to each individual country and unfortunately nothing has been done here in the U.S. yet. But that’s not to say that we can’t, and materials are copyrighted but free of charge. I’ll tell you a little bit later how you can get all of those.

Ric Skinner: I don’t see how HSI is much different than the HVA tools that U.S. hospitals use now. Please contrast the HSI and such tools as the Keiser Permanente HVA spreadsheet.

Pat Bittner:. Rick, I confess I am not familiar with the HVA tools. Perhaps the greatest difference is the stressing of, as I said, safety versus vulnerability, which I know is a semantic distinction. But I would be very interested to see those materials, and if you could send me a link to a website or some descriptive material, I would be glad to get back to you or even get back to the EM Forum—I could post something on the EM Forum, because right now I do not think I would be in the position to make that kind of analysis.

Howard Gwon: How does a hospital obtain a copy of the 145 questions?

Pat Bittner: Howard, at the beginning Amy had mentioned where you can click to see the handouts that were available for the session and one of the handouts said "Hospital Safety Index Flyer", I believe, and that is a two-paged flyer that we have had on the hospital safety index and it gives the website at the top which is www.safehospitals.info, and if you’ll click down or scroll down the home page, you’ll see on the right-hand side "Hospital Safety Index". Click there, and you can download a complete copy of the checklist [http://safehospitals.info/images/stories/3Resources/techGuides/SafeHospFormsEng.pdf] and you can download the evaluator’s guide [http://safehospitals.info/images/stories/3Resources/techGuides/SafeHosEvaluatorGuideEng.pdf] as well. They’re both there, along with our E-mail address and we would welcome any comments.

Bill Lang: What would the disadvantages be of using this with long term care facilities (nursing homes)?

Pat Bittner: Well, I don’t see any disadvantage at all. We had talked about the fact that originally this particular version was produced to look at fairly complex or tertiary level hospitals. You’ll see when you take a look at the questions in the checklist that most of these then do apply to areas that may have surgical wards, or pediatric wards or different facilities (radiological services, etc.), which may not correspond to a long term care facility.

However, there are structural issues that probably would apply to any type of health facility. And we believe, although we haven’t done it yet, that this is scalable, or an index that can be modified. Once you begin to modify the checklist questions, it’s affecting, of course, that calculator module that has been weighted and the formulas applied to it, according to the standards that they used in Latin America and the Caribbean.

But I would think it would be interesting for you, and I would love to hear your feedback, that there are many areas, including the functional aspects that we’re talking about (disaster plans, emergency contingency plans, evacuation plans) that look at the functional continuity of services, or some of the structural elements that look more at the engineering aspects, rather than the many different health services you would find in a complex facility that you wouldn’t necessarily find in a long term facility.

So I hope that would answer the question but I would be very pleased to hear back from any of you on these things once you’ve taken a look at them and see how we could answer some of these questions more fully.

Roger Arango: It seems that this tool would be very helpful if the results could be entered in FEMA's HAZUS model use for disaster impact predictions.

Pat Bittner: I’m not familiar with it. The non-structural elements that the safety index looks at are probably some of the most important. We’re looking at lifelines, the electrical system, the water storage, telecommunications, heating, ventilating and air conditioning, many of these things that you will find in any king of a health facility, office furniture and equipment, any medicinal gasses that may be used (oxygen, nitrogen, things like that) and how they’re stored.

Many of the architectural elements are also—doors, entryways, windows, ceilings—things that can have a major impact on a hospital because in most of the cases, or the case that I cited in Mexico, which really opened everybody’s eyes, is not by any means the norm. In 95% of the cases, we see that a hospital is just simply not able to function, and it’s not because it has collapsed; it’s because it’s either flooded or the electrical system is down, there’s no water, surgeries can’t be performed, patients can’t be attended to.

How many times have we seen patients having to be taken care of in either tents or mobile hospitals on the grounds of a hospital, which for all intents and purposes looks like it’s still standing but is has been rendered useless?

Isabel McCurdy: Time parameter involved once you implement this safety tool?

Pat Bittner: Generally it can be, depending on the size of the facility (let’s take the highest level complex health facility or referral hospital) it will generally not exceed two days. In many cases it can be done in one day. You as a country, or you as a hospital director, can compose your evaluation team in a fairly flexible manner.

If you have a larger hospital and consequently a larger evaluation team, many times you can break this team out into separate areas so you don’t walk around as one large group and do this. But rather, the engineers or architects or maintenance people can look at the structural and non-structural, and perhaps the hospital disaster committee representative can look at the functional aspects. What’s important is that at the end of this, whether it be one day or two days, (but it will not exceed two days), the sub-teams will then re-group so that they have one common assessment that they will input into the safety calculator.

Avagene Moore: Pat, this is an interesting program. How much time and training is needed for the teams? Can it be done with the written information you provide?

Pat Bittner: Our experience to date, over the last 18 months has been to hold a 4-day training session for the evaluation teams. In Mexico alone, 900 people have been trained. Just in the past month alone we have geared up another series of training events in the Caribbean, in Central America and South America. All told, there is probably close to 2,000 evaluators that have been trained. That sounds like a lot but you know that there’s a big turnover in many of these health professions. You may have 10 people trained in Honduras but at the moment you want to apply the index you can’t put your finger on them or they can’t be released or whatever, so it’s necessary to build up a critical mass.

We do recommend a face-to-face training because I think the feedback you’re going to get from other participants there will help build a certain kind of common understanding of how this is going to be applied. So there’s been a four-day training, and in Mexico we are trying to begin similar modules to their online training course, which I can send you all the URL for (I don’t have it on hand at the moment, and it is in Spanish only) for which they will certify somebody as a hospital evaluator using the hospital safety index. I think that it would at least require a little bit more than reading the materials (the evaluators guide that is out there) because there is a methodology and a rationale behind the application of this that is good to learn about.

Amy Sebring: The guide that is in Spanish, this will be published in English?

Pat Bittner: All the guides and the checklist and the guide for evaluators are all in English and they’re all available for downloading at the website whose address that is on the flyer. What I mentioned that is in Spanish was the course that is produced by the government of Mexico, the follow-up to the training course. The training course, unfortunately, the standardized materials right now are in Spanish.

There is a course going on in the Caribbean (in the next 2 days it will begin) and probably the presenters have done their own individual power-points which I will try to get copies of and post on that same website, if you can check back to that website for some of those updates. But right now the core components of the hospital safety index—the guide for evaluators, the checklist forms and the safety index calculators—are on the website.

I’m very interested as PAHO to learn more about some of these issues here in the U.S. and I think my E-mail address [[email protected]] is on the front page and I’d be pleased to receive any other links or actual tools or documents that you have on some of these. It would be very good to share with some of the trainers who are doing the training for the evaluation teams—things that we may not have been considering. Of course, the context here in the U.S. is a little bit different than in the Caribbean, Latin America, but in many Latin American cities (Sao Paulo, Mexico City—these are huge metropolitan areas) I’m sure the hospitals are just like they are in the U.S.

Ric Skinner: In U.S. Joint Commission requires an annual HVA. Is HSI required by any regulating or accrediting organizations?

Pat Bittner: Great question. That is our ultimate goal. The Joint Commission of course is the U.S. regulating body and we’ve got 28 member countries in Latin America and the Caribbean that we will have to convince of this. We always tell countries that this is not an elusive goal. We can make our hospitals safer from disasters. But it is too big a job for the health sector alone; it requires political commitment and some type of a regulatory framework, and if the hospital safety index is not the right thing at least it’s a starting point for them to begin to recognize that this is something they have got to take into account.

There are many reasons for wanting to make hospitals safe in addition to the health reasons—the socioeconomic impact, there’s political and economic decisions. We keep losing these same facilities time and again, or at least until they’re rendered non-functional. In the Caribbean, one hospital lost its roof in ten successive hurricanes until they finally made the political commitment to do this correctly and not just do a patchwork job of refurbishing the hospital. So we do need this political commitment, and this would be one of our goals to use this or a similar tool as an accreditation standard.

Isabel McCurdy: Is there refresher courses for the evaluators?

Pat Bittner: No, there isn’t, Isabel. I think it may be because it may be still kind of new and we’re still trying to reach that critical mass doing the training that’s there. PAHO has always with anything we’ve done has tried to leave the capacity in the countries itself and we’ve just about touched all the regions and sub-regions.

Now we’ll concentrate a lot of training the trainers and that might be where we can get our actual best return on investment. They will be able to do the refresher courses much easier if we leave the trainers in each of the different countries. They would then be encouraged to do that refresher.

Julie Bulson: It will not only take political support but since most hospitals do not have budgets for emergency management, it will take financial support as well.

Pat Bittner: You’re right, it won’t take only political support, which is why this hospital safety index is a tool within a broader regional program on safe hospitals, which has been going on since the mid-1990s. One of the basic strategic directions of this program is to involve more than the politicians, but it also involves (and we’ve done this in every country) ministries of planning, ministries of finance.

We don’t want the health sector or hospitals to have to take the land that is left over in a country but we always want them to consider vulnerability to hazards before they build a hospital. We’re working extensively with the World Bank and the Inter-American Development Bank long-range to make sure as they consider environmental impact statements when they grant loans to health infrastructure that they are also going consider vulnerability to hazards.

We’ve got a number of programs going on with them right now to increase this awareness and they’re becoming very open to it and that is very encouraging. You’re absolutely right, the health sector doesn’t control much of what goes on here. You’ve got the political commitment but you’ve also got to have the ones who control the purse strings.

Ric Skinner: You won't find a more political up hill to climb than getting the JC to support HSI which may take more hospital resources or money to implement than the tools being used now.

Roger Arango: In the US emergency management "Emergency Support Function" (ESF) system, hospital issues do not get much visibility from emergency managers. This is a major system problem in emergency management.

Pat Bittner: We’ve found the same issue for decades in Latin American and the Caribbean as well and I think a lot of times you’ll get much more in terms of attention to bridges or other infrastructure that sometimes we think is almost considered more critical in the eyes of some than hospitals, and we’ve come to the conclusion that the health sector (and I’m speaking of Latin America and the Caribbean now—I’m not well-versed in the reality in the U.S.) itself has to do part of the job in asserting their stance in national disaster committees that will take this as the most serious and critical of the infrastructures.

There was a world campaign on safe schools, and it’s very easy to sell a school. They did a really good job in marketing and packaging this and the vulnerability and the children, and all that. It’s a little bit more difficult to sell the idea of safe hospitals, but when the rubber meets the road, it is the one thing that you are going to want to be there when a disaster strikes, and it’s the one facility that occupied 24 hours a day, 7 days a week, it’s the facility with the most vulnerable of all populations. The health sector has to do a little bit more to increase their outreach to other sectors and engage them in this particular fight.

Paul Garwood: WHO is planning its World Health Day for 7 April 2009, which is expected to be based on the subject of "health facilities in emergencies," and we have been lucky to have the assistance of Pat and other colleagues globally. Pat has said that the index focuses on the PAHO region, but how do you see the potential applicability of aspects of the index to other parts of the world?

Pat Bittner: One of our WHO colleagues from the Eastern Mediterranean regional office, Dr. Dr. Qudsia Huda, WHO’s Eastern Mediterranean regional office has begun a series of trainings using the hospital safety index to determine what modifications they may have to make according to the realities in that region. So we are only beginning (may I also say that WHO’s Southeast Asia regional office based in Delhi but covering all of that area of the world has also begun to do the same).

I’m sure that modifications will have to be made, but I think that more than anything this will serve as a framework vehicle. I’m glad Paul brought up World Health Day because PAHO is one of WHO’s six regional offices, and we would like to try to make this not this as a proprietary tool with that name and PAHO logo or the WHO logo but as a tool that is put to the service of the countries and it’s up to them then to decide how applicable this is. They’re in that beginning stage right now.

Frannie Edwards: Has PAHO looked at the California Hospital Building Safety Board and the California Alquist Hospital Safety Act, and the related continuity of service regulations?

Pat Bittner: I will definitely take a look at those, Frannie. This has been just as informative for me and I will Google those when we’re through.

Kent Schod: I would agree that medical facilities need better communications with E/M; however, hospitals need to take active rolls in employing E/M professionals to bring the disaster preparedness levels up to the similar standards seen in other critical infrastructure groups. Hospitals need to also be willing to adopt the existing, functional programs already available from FEMA and DHS.


Amy Sebring: Time to wrap for today. Thank you very much Pat for an excellent job. And thanks to all our participants for great questions and comments. Please stand by just a moment while we make a couple of quick announcements.

Again, the recording should be available later today and the transcript on Friday. If you are not on our mailing list and would like to get notices of future sessions and availability of transcripts, just go to our home page to Subscribe.

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Thanks to everyone for participating today. We stand adjourned but before you go, please help me show our appreciation to Pat for an excellent job by typing or drawing on this Thank You Note!