Analysis of Hospital’s Emergency and Disaster Preparedness Using Hospital Safety Index in Indonesia

Round 1

Reviewer 1 Report

The article deals with assessing the capacity of Indonesian hospitals to respond to disasters. The topic is relevant, and works on the subject are relatively scarce,

 

MAJOR COMMENTS

- There is a need for extensive revision in the English language, preferably by a native speaker. There are many problems with the nominal agreement, verbal agreement, punctuation, text fluidity, etc.

- L. 72. Define "facilities' risk facing disasters."

- It is necessary to better detail information about the index. i. e. how the index combines information from the indicators that compose each module?

- L. 102. Which information from the population?

- L. 105. Explain why module 1 is not included in the index and, if not, what is the relevance for the work.

- L. 112. It is also necessary to assess the structural integrity facing fires regarding fire protection systems.

- L. 126 It is recommended that general revision be presented before more specific issues (2.2 before item 2.1).

- L. 134 It is necessary to present and define the risk index score and its range values.

- L.187: please clarify the criteria used to choose the sample and define "purpose sample".

- L. 198 who and how many are the key respondents? Based on which criteria were They selected?

- L. 199. What kind of interview? (non) Structured?

- L. 203 how many evaluators? What is the temporal interval?

- Please detail the modules weighting (values and criteria).

- L. 221 It is important to be aware of risk scenarios; that is, damage caused by hazards depends on hazards' magnitude and should be treated under different magnitude scenarios.

- It is necessary to detail the items that compose each module in the HSI calculation.

- In each module that composes the HSI, it is necessary to better develop the conclusions and limitations of each risk category.

- L.288. All samples?? Or all the sample population?

- In section 5, it is necessary to explore better the items that showed critical values (individual scores in C band) and better detail the items' weighting.

- L. 309 Potential disaster?? Do authors mean disaster risk? Note that disaster is the damage caused by the combination of hazard and population's vulnerability / exposure, and disaster risk is the likely damage.

- L. 323. Population density is not a threat but is part of vulnerability.

- L.325 hazard  vulnerability?? I recommend that the authors revise the following concepts adopted by UNDRR: susceptibility, hazard, vulnerability, exposure, risk.

- It is necessary to deepen the analysis presented for each module; the discussion is relatively superficial and does not explore the causes of the problems and how to improve them. When authors compare similar situations in different countries, explaining these similarities, contexts, and roots is necessary.

- Clarify lines 341-343.

- Clarify lines 367-370.

It would be interesting to contextualize the difficulties and challenges faced by the hospitals in previous disaster situations, either in a qualitative way.

- It is not clear the relevance of the multi correspondence analysis for the paper. For example, do the authors need MCA to conclude what is exposed in section 5.5??

- In section 6, for the first time, it is mentioned COVID-19 situation. Don't authors think this particular situation deserves further development since it heavily affects the hospital's capacity? Is HSI still a useful tool for hazards that occur under covid-19 restrictions? In Other words, how covid 19 restrictions affect HSI?

- Section 6 is currently presented as a repetition of the main results and lacks limitations analysis.

 

MINOR COMMENTS

 

- The text looks like it hasn't been proofread enough; it has different colors in different parts of the text, as well as repeated paragraphs (i.e., lines 105-120, 277-281).

- L.57. 6,4 "million" instead of 6,4 "mission"?

- Please clarify l. 59 and 60. Positive cases 2093962 (accumulated) and positive cases (daily) 194776?

- In many sentences, the authors are too generic in citing Other works. i.e., l. 68: ...some studies... L. 71: ... the Other study... L. 131: ... some studies... It is necessary to adopt the journal citation pattern.

- L.91 and others: check journal citation pattern in all the text.

- L. 137 "Jakarta IS also"??

- Figure 1 and others: texts are illegible, translated to English, which processes integrate the risk map?

- L.250 It seems the right category is B and not A.

- L. 320 Sumatera?

- L.329 Many disasters are not just natural: landslides, floods, and others are influenced by men's actions changing in the natural environment. These may be called socio-natural disasters.

- L. 373 lowest "score"?

Author Response

Responses to Reviewer 1

 

The article deals with assessing the capacity of Indonesian hospitals to respond to disasters. The topic is relevant, and works on the subject are relatively scarce, 

 

MAJOR COMMENTS

- There is a need for extensive revision in the English language, preferably by a native speaker. There are many problems with the nominal agreement, verbal agreement, punctuation, text fluidity, etc.

General Response:

Dear Sir/Madam, thank you for kind feedback. We have tried to update our manuscript according to your feedbacks.

- L. 72. Define "facilities' risk facing disasters."

Response:

It has been amended to as per reviewer comment:

“The other study in 2 public health centre facilities in DKI Jakarta also reported that those healthcare facilities are still at risk in facing disasters, including structural and non-structural safety [12]. Public health centre facilities provide in-patient and out-patient for community primary healthcare services as well as public health prevention and promotion for infectious diseases and non-infectious disease [12]. Various disaster risks facing by public health centre facilities in DKI Jakarta including floods, blackout and earthquake, since the electricity backup only limited for 1-2 days while the electricity blackout in 2019 last until 3 days [12].”

-It is necessary to better detail information about the index. i. e. how the index combines information from the indicators that compose each module?

Response:

The index comprises several modules including understanding the multi-hazards encountered the hospital facilities (module 1); structural safety that describes how the hospital’s structure ensures the safety of workers, patients and visitors (module 2); non-structural safety that describes how the hospital’s facilities and utilities such as water, electricity, communication and medical gases remains operational during or after the disaster (module 3); disaster management that describes how the hospital managed different types of hazards including disaster management committee and address all hazards encountered by the hospital and its relevant procedures (module 4). The Hospital Safety Index combined all information from all the modules and the indicator which describes as a whole picture about hospital disaster preparedness and resilient.

- L. 102. Which information from the population?

Response:

Population information include number of populations surrounding the hospital, population density, disaster vulnerability of the population; this information is not provided in this article but normally recorded during the hospital safety index evaluation process for hospital accreditation and for districts disaster contingency plan.

- L. 105. Explain why module 1 is not included in the index and, if not, what is the relevance for the work.

Response:

Module 1 is not included in the Hospital Safety Index (HSI) calculation as per guidance on WHO but providing a variety of potential hazards posed by the hospital (it is describe in section 2.1 and 4.1 of this article). Even though the module 1 is not included in the HSI calculation, but the information describes in the Module 1 provide detail explanation about several hazards including natural hazards, non-natural hazards and man-made hazards posed by the hospital. It is a very important initial information whether the hospital will address all hazards identified in Module 1. Population information include number of populations surrounding the hospital, population density, disaster vulnerability of the population; this information is not provided in this article but normally recorded during the hospital safety index evaluation process for hospital accreditation and for districts disaster contingency plan.

- L. 112. It is also necessary to assess the structural integrity facing fires regarding fire protection systems.

Response:

It has been included in Module 2 Non-structural safety indicator 2 - Fire Protection System (Table 2 indicator 2.d) – several paragraph has mention and discuss about this already.

- L. 126 It is recommended that general revision be presented before more specific issues (2.2 before item 2.1).

Response:

The section of 2.2 has been changed into 2.1 and vice versa.

- L. 134 It is necessary to present and define the risk index score and its range values.

Response:

it has been added as shown in Figure 1, there are 3 risk classification, namely (low <13), medium (13-144), and high (>144)

- L.187: please clarify the criteria used to choose the sample and define "purpose sample".

Response:

Sampling method used in this study was purposive sampling. The hospital selected based on the purpose of the study where the hospital has not examined yet the HSI level, Hospital Type B (provincial hospital) and Type C (regency hospital),

- L. 198 who and how many are the key respondents? Based on which criteria were They selected?

Response:

Selected key informants include 3 members, namely hospital disaster team, building facility service personnel, and public health officer working at the selected hospital with minimum duration of work is 1 year.

- L. 199. What kind of interview? (non) Structured?

Response:

Data were collected from the key informants through Direct interview according to HIS tools to the person in charge of their respective units

- L. 203 how many evaluators? What is the temporal interval?

Response:

Data were collected by 8 evaluators with backgrounds in public health (2 evaluators), nursing (2 evaluators), disaster management (2 evaluators), and civil engineering (2 evaluators). 

- Please detail the modules weighting (values and criteria).

Response:

We have already described as follow:

There were two data analysis methods applied in this study. The first method was based on the HSI Guidance to determine the hospital disaster preparedness level. Each item in the HSI was scored with 1, 0.5, or 0, which indicate high, average, or low, respectively. The score from each module namely structural safety, non-structural safety, and emergency and disaster management modules were obtained by dividing the total score with the number of items.

The weighting for each module were determined based on the HSI Guidance. If there is a higher risk of earthquake, it is recommended that the structural safety should have a weighted value of 50%, the non-structural safety 30% and the emergency and disaster management 20%. After multiplying the weighted value with scores of each module, the final score of each module were then added up and safety index was obtained.

- L. 221 It is important to be aware of risk scenarios; that is, damage caused by hazards depends on hazards' magnitude and should be treated under different magnitude scenarios.

- It is necessary to detail the items that compose each module in the HSI calculation

Response:

The risks scenarios have been mentioned in section 2 Literature review, which is according to Hospital Safety Index with items that have been evaluated.

Response

The Hospital preparedness was assessed using Hospital Safety Index: Guide for Evaluators 2nd Edition. This tool includes four modules, namely, disaster hazard and risk; structural safety (18 items); non-structural safety (93 items); and emergency and disaster management (40 items). Each module addresses different aspects based on 4 modules, namely Potential hazard and disaster, Structural Safety, non-structural safety, and Emergency and Disaster Management

- In each module that composes the HSI, it is necessary to better develop the conclusions and limitations of each risk category.

Response

Hospital with Category A mean the hospital will function in emergencies and disasters. It is recommended, however, to continue measures to improve emergency and disaster management capacity and to carry out measures in the medium- and long-term to improve the safety level in case of emergencies and disasters

Hospital with Category B mean Hospitals still carry risks when dealing with disasters in this variable. It is recommended to improve all element (structural, non structure and emergency disaster management)

 

Response:

- L.288. All samples?? Or all the sample population?

Response:   

All the population sample.

- In section 5, it is necessary to explore better the items that showed critical values (individual scores in C band) and better detail the items' weighting.

Response:

Already put in the parentheses after each category

- L. 309 Potential disaster?? Do authors mean disaster risk? Note that disaster is the damage caused by the combination of hazard and population's vulnerability / exposure, and disaster risk is the likely damage.

Response:

I meant the hazards are not potential disaster or disaster risk, but a dangerous phenomenon, substance, human activity or condition that may cause various adverse effects (UNISDRR).

- L. 323. Population density is not a threat but is part of vulnerability.

 Response:

Yes, population density and urbanization will increase vulnerability to disasters.

- L.325 hazard  vulnerability?? I recommend that the authors revise the following concepts adopted by UNDRR: susceptibility, hazard, vulnerability, exposure, risk.

Response:

Thank you for feedback.Hazard Vulnerability Assessment (HVA) method is one of theory and approach using by Hospitals in DK Jakarta.

- It is necessary to deepen the analysis presented for each module; the discussion is relatively superficial and does not explore the causes of the problems and how to improve them. When authors compare similar situations in different countries, explaining these similarities, contexts, and roots is necessary.

Response:

Thank you for advice. We have elaborated your concern in discussion section

- Clarify lines 341-343.

Response: T

hank you for concern. It has already updated

Indeed, this high-risk condition affects the structural safety element in the building such a hospital, and HSI has become to be the most vital parameter for ensuring the hospital readiness in Indonesia which have been potentially facing many types of emergencies and disasters.

- Clarify lines 367-370.

Response:

In non-structural safety, there are 4 elements that have been assessed according to Hospital Safety Index tools used, consisting architectural safety, Infrastructure protection, access and physical security, critical systems, and equipment and supplies.

It would be interesting to contextualize the difficulties and challenges faced by the hospitals in previous disaster situations, either in a qualitative way.

Response:

Thank you for your concern. Even though we tried to illustrate these situations in the section of 2.2 regarding the overview of the area study.

- It is not clear the relevance of the multi correspondence analysis for the paper. For example, do the authors need MCA to conclude what is exposed in section 5.5??

Response:

As mentioned in paper that MCA was used to further analyse the data and find the relationship among categorical variables. Based on the MCA results above, we can identify and cluster which province in Indonesia tend to have same problems regarding to disaster management variables on Hospital Safety Index. Section 5.5 has explained the details of the MCA results.

- In section 6, for the first time, it is mentioned COVID-19 situation. Don't authors think this particular situation deserves further development since it heavily affects the hospital's capacity? Is HSI still a useful tool for hazards that occur under covid-19 restrictions? In Other words, how covid 19 restrictions affect HSI?

Response:

We have updated this section. Further, during the current situation of COVID-19, the role of hospital even further crucial as referral of the COVID-19 patient with severe symptom who need intensive health care. In some areas, disaster triggered by natural hazard occurred simultaneously with the pandemic which made health care system function including health care services in the hospital even more critical. Hence, ensuring that Hospital capability remains operational during disaster is very important, involving by assessing HSI level.

- Section 6 is currently presented as a repetition of the main results and lacks limitations analysis.

Response:

We have already updated in section 6.

 

MINOR COMMENTS

- The text looks like it hasn't been proofread enough; it has different colors in different parts of the text, as well as repeated paragraphs (i.e., lines 105-120, 277-281).

Response: Thank you we have already updated.

- L.57. 6,4 "million" instead of 6,4 "mission"?

Response: We have already updated this section from data 2020 to 2021

Those disasters could endanger people, infrastructure, and construction. During 2021, it was reported that 2,009 disaster cases occurred in Indonesia. The top 4 cases were flooding, typhon, land slide, and forest fire. The disasters caused 709 death, 73 missing, 13,088 injured, and 5,084,979 suffered and displaced persons. Furthermore, the disasters also damaged 1542 facilities including 356 health facilities [5].

- Please clarify l. 59 and 60. Positive cases 2093962 (accumulated) and positive cases (daily) 194776?

Response:

The positive cases in Indonesia as of 31 January 2022 were about 4,353,370 cases with 194,776 positive cases, 4,140,454 healing cases and 144,320 death cases [7].

- In many sentences, the authors are too generic in citing Other works. i.e., l. 68: ...some studies... L. 71: ... the Other study... L. 131: ... some studies... It is necessary to adopt the journal citation pattern.

Response:

We have updated this section.

Sunindijo et al., has conducted a study to 10 hospitals in West Java and 5 hospitals in Yogyakarta which reported the average preparedness level for hospital to be well-functioning during and after disaster are still at-risk, which still require some interventions as soon as possible [11].

The other study conducted by Firdausi et al., in 2 public health facilities in DKI Jakarta also reported that those facilities are still at risk in facing disasters [12].

A study reported by UNDRR highlighted that Jakarta will be sunk in the next 20 years and claimed as the fastest sinking city in the world [42], which means Jakarta is also prone to earthquake.

Study reported by Djalali et al., on the hospital in Sweden and Iran shown that financial aspect become a focus in the study and required special attention because finance is considered to be an important aspect in the implementation of hospital emergency and disaster management in both countries [68].

- L.91 and others: check journal citation pattern in all the text.

Response

Thank you we have already updated

- L. 137 "Jakarta IS also"??

Response

It means Jakarta province is also prone to..

- Figure 1 and others: texts are illegible, translated to English, which processes integrate the risk map?

Response: We have already translated into English, except the name of area.

- L.250 It seems the right category is B and not A.

Response: The correct category is A. Safety Index A is 0,66-1.

From the results of the assessment carried out hospitals in DKI Jakarta and Yogyakarta Province are in category A (the hospital safety index is 0.66-1.00)

- L. 320 Sumatera?

Response: Yes, It means Sumatera

- L.329 Many disasters are not just natural: landslides, floods, and others are influenced by men's actions changing in the natural environment. These may be called socio-natural disasters.

Response: Thank you we have already amended this section

- L. 373 lowest "score"?

Response: Yes, it means the lowest score. We have already updated.

 

Author Response File: Author Response.pdf

Reviewer 2 Report

The paper is well-written and addresses a topic that is currently popular in disaster management. It’s a well-written piece. I believe it can be considered for publication after addressing some issues, one of which is a lack of sufficient literature review, which I believe can be addressed in the manuscript.

Despite the fact that there are numerous similar studies in the literature, the authors choose to ignore them. There should be an additional section added to this paper, and recent studies should be addressed and critically analysed, for example:

1. Mojtahedi, M., Sunindijo, R. Y., Lestari, F., Suparni, S., & Wijaya, O. (2021). Developing Hospital Emergency and Disaster Management Index Using TOPSIS Method. Sustainability, 13(9), 5213.
2. Yazdani, M., Mojtahedi, M., Loosemore, M., Sanderson, D., & Dixit, V. (2021). Hospital evacuation modelling: A critical literature review on current knowledge and research gaps. International Journal of Disaster Risk Reduction, 66, 102627.
3. Aghapour, A. H., Yazdani, M., Jolai, F., & Mojtahedi, M. (2019). Capacity planning and reconfiguration for disaster-resilient health infrastructure. Journal of Building Engineering, 26, 100853.

In addition, the authors recently published a paper entitled “The Application of Hospital Safety Index for Analyzing Primary Healthcare Center (PHC) Disaster and Emergency Preparedness” the differences between this study and the current paper should be discussed.

“Disaster” or “Hazard”? Please keep consistency in the paper.

The research aim, objective and contributions of this study should be highlighted in the introduction.

Please improve the presentation of table 5. It looks a bit messy.

Author Response

Responses to Reviewer 2

 

The paper is well-written and addresses a topic that is currently popular in disaster management. It’s a well-written piece. I believe it can be considered for publication after addressing some issues, one of which is a lack of sufficient literature review, which I believe can be addressed in the manuscript.

Despite the fact that there are numerous similar studies in the literature, the authors choose to ignore them. There should be an additional section added to this paper, and recent studies should be addressed and critically analysed, for example:

1. Mojtahedi, M., Sunindijo, R. Y., Lestari, F., Suparni, S., & Wijaya, O. (2021). Developing Hospital Emergency and Disaster Management Index Using TOPSIS Method. Sustainability, 13(9), 5213.
2. Yazdani, M., Mojtahedi, M., Loosemore, M., Sanderson, D., & Dixit, V. (2021). Hospital evacuation modelling: A critical literature review on current knowledge and research gaps. International Journal of Disaster Risk Reduction, 66, 102627.
3. Aghapour, A. H., Yazdani, M., Jolai, F., & Mojtahedi, M. (2019). Capacity planning and reconfiguration for disaster-resilient health infrastructure. Journal of Building Engineering, 26,

100853.

Response:
Thank you for positive feedback, We have already developed by adding some references as your recommendation.

In addition, the authors recently published a paper entitled “The Application of Hospital Safety Index for Analyzing Primary Healthcare Center (PHC) Disaster and Emergency Preparedness” the differences between this study and the current paper should be discussed.

Response:

There are significant differences between the two studies, especially in terms of location and instruments used

“Disaster” or “Hazard”? Please keep consistency in the paper.

Response:

We use 2 terms, disaster and hazard with different purposes. Hazard is anything that can cause loss, either death, injury, illness, or property loss. while disaster is one of the consequences of a hazard whose risk cannot be controlled.

The research aim, objective and contributions of this study should be highlighted in the introduction.

Response:

It has been mentioned in introduction section.

Please improve the presentation of table 5. It looks a bit messy.

Response: thank you we have already updated.

 

 

Reviewer 3 Report

The main problem of the article, in my opinion, is that it does not correspond to the topic of Sustainability. Unless it was given to some Special Issue, but it is not visible. In addition to this essential point, there are areas for improvement:
1. The introduction, like the whole text, lacks an interface with Sustainability. It is also unclear what the main problem is and what the purpose of this article is.
2. In the literature review 2.1.1 et al. subdivisions are too small in scope and should be left in full text.
3. The analysis of results section contains only the statement of facts, but does not show the reasoning of the authors themselves, and what is the fact that such results, etc. Perhaps it would be expedient to think about combining the sections of results and discussion
4. It may be appropriate to move Table 5 to the Annexes.
5. At the end of the conclusions, to emphasize the directions of long-term research more.

Author Response

Responses to Reviewer 3

The main problem of the article, in my opinion, is that it does not correspond to the topic of Sustainability. Unless it was given to some Special Issue, but it is not visible. In addition to this essential point, there are areas for improvement:

1. The introduction, like the whole text, lacks an interface with Sustainability. It is also unclear what the main problem is and what the purpose of this article is.

Response:

Indonesia has experienced a lot of disasters which destroyed healthcare facilities and render them non-functioning. For instance, Yogyakarta earthquake in 2006 destroyed 1590 healthcare facilities’ and West Sumatera earthquake destroyed 744 healthcare facilities as we described in introduction. The hospitals experienced structural and non-structural collapsed. Based on these experiences, it was realized the other hospitals in Indonesia were also vulnerable for disasters. Therefore a mitigation program are urgent to be carried out to reduce further hospital damage in the future such as evaluation of hospital readiness. There is limited study in Indonesia that conduct assessment of hospital preparedness comprehensively. 

 

The objective of this study was to assess the level of hospital preparedness in Indonesia with WHO/PAHO Hospital Safety Index

 

2. In the literature review 2.1.1 et al. subdivisions are too small in scope and should be left in full text.

Response:

Thank you for suggestion, we have already revised this section.

3. The analysis of results section contains only the statement of facts, but does not show the reasoning of the authors themselves, and what is the fact that such results, etc. Perhaps it would be expedient to think about combining the sections of results and discussion

Response:

Thank you for suggestion.

4. It may be appropriate to move Table 5 to the Annexes.

Response: thank you for recommendation. It has been moved to Annex 1

5. At the end of the conclusions, to emphasize the directions of long-term research more.

Response:

It has already added in conclusion section. Further studies can be carried out by investigating determinant factors of hospital preparedness in Indonesia.  It is also needed to analyse the difference preparedness levels among hospital’s in Indonesia by comparing the type of hospitals and their preparedness.  Moreover, long term research can be conducted by comparing the hospital preparedness and their real readiness when disaster occurs to assess the reliability of hospital safety index tool.

Author Response File: Author Response.pdf

Reviewer 4 Report

The aim of this paper is to examine the level of hospital safety index in 9 hospitals in four provinces according to the guidelines from WHO/PAHO. Overall, the concept of this paper is promising, the structure of the paper is correct and it offers some good arguments.

The main strengths of this paper are the following:

• The title accurately reflects the content of this study.
• Methodology is sound.
• The tables and figures are presented clearly and analyzed appropriately.

First of all, the abstract of the paper is complete and stand-alone. Authors mentioned the objective as well as the practical implication of this research. Furthermore, Authors provided some details about the methodology used and highlighted the practical contribution of the paper.

The Introduction is focused. Authors used the traditional structure in order to justify the research gap and the motivation as well as the value of this paper. Authors presented the motivation of the paper and discussed about the main findings. However, it is necessary to improve the theoretical and practical contribution of this paper. Authors should answer the following questions in order to make the contribution of the paper explicit:

• What does this research tell us that we didn’t already know?
• What is the contribution of the most significant results of the paper?

 A theoretical background which presents the results of previous surveys is necessary to be added. It will strengthen the contribution of this paper and it will highlight what is new or unexpected in this work.

The research on which the paper is based is well designed and the methods that have been employed are appropriate. However, the authors should attempt to enhance the following: (i) What are the questions used in the questionnaire? (ii) Is this section designed based on the existing literature?

The findings are a good basis for discussion but they need more conceptualization to make the contribution of the research more evident. Thus, results can be synthesized in ways that help unleash new insights in this discipline. Authors should compare these results with the findings from previous similar studies.

The paper does not clearly identify any implications for research, practice and/or society. Furthermore, it does not bridge the gap between theory and practice. This part should be more critical and generic by emphasizing how the study makes contribution to the field as well as open the doors for the future of this field. Authors should answer the following questions in order to make the contribution of the paper explicit:

• Why is this paper significant and to whom?
• What will be the impact of the paper to academic research and industry practice?

Finally, when it comes to the limitations, authors should be transparent about the ways that the choices made during the study have limited the scope and reach of the findings. This can also open avenues for further research on the topic, and allow them to reflect upon how future endeavors can address the limitations of this work, but also how this work can offer opportunities for future research on the topic. These sections are currently considerably restricted in this paper.

Author Response

Response to Reviewer 4

The aim of this paper is to examine the level of hospital safety index in 9 hospitals in four provinces according to the guidelines from WHO/PAHO. Overall, the concept of this paper is promising, the structure of the paper is correct and it offers some good arguments.

The main strengths of this paper are the following:

• The title accurately reflects the content of this study.
• Methodology is sound.
• The tables and figures are presented clearly and analyzed appropriately.

Response:

Thank you for the feedback

First of all, the abstract of the paper is complete and stand-alone. Authors mentioned the objective as well as the practical implication of this research. Furthermore, Authors provided some details about the methodology used and highlighted the practical contribution of the paper.

The Introduction is focused. Authors used the traditional structure in order to justify the research gap and the motivation as well as the value of this paper. Authors presented the motivation of the paper and discussed about the main findings. However, it is necessary to improve the theoretical and practical contribution of this paper. Authors should answer the following questions in order to make the contribution of the paper explicit:

• What does this research tell us that we didn’t already know?

Response:

Ensuring the functionality of hospitals and making them safe in the event of disasters poses a major challenge, not only because of the high number of hospitals and their high cost but because there is limited information about current levels of safety and emergency and disaster management in hospitals

 

• What is the contribution of the most significant results of the paper?

Response:

Result of this paper practically significant because damages to hospitals during disasters complicate relief measures due to delay in treatment of trauma and other diseases. Damaged hospitals also cause secondary disasters by compromising the achievement of national and global health goals, and by creating political risk for governments (Mani et al., 2016).

Result of this paper economically significant because of the economic and social costs associated with the damages to hospitals during disasters. Hospitals represent more than 70% of public spending on health in countries (World Health Organization, 2015). Studies on post major disasters found that damages to hospitals and health care facilities were estimated to be within a range of 61 to 214 days of government health spending on the entire population (International Strategy for Disaster Reduction, 2007). Population increase, climate change, and urbanisation are bound to worsen natural disasters in the future, thus resilient hospitals are an immediate necessity for Indonesia.

Hospital Safety Index is innovative in offering a new perspective on the disaster readiness of hospitals in Indonesia. It is critical that hospitals continue to work during emergencies and disasters since people immediately go to the nearest hospital for medical assistance when emergencies occur, without considering whether the facilities might not be functional. Consequently, it is vital to identify the level of safety and functionality a hospital will have if an emergency or disaster occurs. Hospital evaluations aim to identify elements that need improvement in a specific hospital or network of hospitals, and to prioritise interventions in hospitals that, because of their type or location, are essential for reducing the mortality, morbidity, disability and other social and economic costs associated with emergencies and disasters (World Health Organization, 2015). This is a crucial step in offering recommendations to strengthen the resiliency of health care facilities in Indonesia, which is a disaster-prone country.

 

 

A theoretical background which presents the results of previous surveys is necessary to be added. It will strengthen the contribution of this paper and it will highlight what is new or unexpected in this work.

Response:

It has been mentioned in background that Hazard-prone Indonesia experience regular disasters, such as earthquakes, volcanic eruptions, floods, and landslides, which have the potential to destroy or damage hospitals and render them non-functioning. For example, an earthquake in 2009 damaged 85 hospitals and health facilities in Padang, West Sumatera. Hospitals are important infrastructure that should always remain safe and operational. Their continuous operations are particularly important in disaster management. In this case, a safe hospital is a facility whose services remain accessible and functioning at maximum capacity, and with the same infrastructure, before, during, and immediately after disasters. The continuing functionality of the hospital depends on a range of factors, including the safety of its buildings, critical systems and equipment, the availability of supplies, and the emergency and disaster management capacities of the hospital, particularly for response to and recovery from hazards or events which may occur.

 

The research on which the paper is based is well designed and the methods that have been employed are appropriate. However, the authors should attempt to enhance the following: (i) What are the questions used in the questionnaire? (ii) Is this section designed based on the existing literature?

Response:

2. The questions used in the questionnaire was according to Hospital Safety Index published by WHO that have already described on section 2. The Hospital preparedness was assessed using Hospital Safety Index: Guide for Evaluators 2nd Edition. This tool includes four modules, namely, disaster hazard and risk; structural safety (18 items); non-structural safety (93 items); and emergency and disaster management (40 items). Each module addresses different aspects as follows [8]:
3. Yes, it is. According to Hospital Safety Index as mentioned in part i)

The findings are a good basis for discussion but they need more conceptualization to make the contribution of the research more evident. Thus, results can be synthesized in ways that help unleash new insights in this discipline. Authors should compare these results with the findings from previous similar studies.

Response:

The findings from previous similar studies ini Primary Health Care that PHCs would be able to recover during disasters but several services would be exposed to danger. The results suggested that there are several gaps that need urgent interventions to be applied for the structural safety of buildings, water supply systems, fuel storage, disaster committee organization, furniture and fittings, offices and storage equipment, as well as increasing the capacity of workers through a structured and systematic training framework for disaster readiness. The results from this study can be used for prioritizing budgets and resource allocation, cost planning, providing specific solutions for local and national government, and efforts to achieve disaster risk reduction.

The paper does not clearly identify any implications for research, practice and/or society. Furthermore, it does not bridge the gap between theory and practice. This part should be more critical and generic by emphasizing how the study makes contribution to the field as well as open the doors for the future of this field. Authors should answer the following questions in order to make the contribution of the paper explicit:

• Why is this paper significant and to whom?
• What will be the impact of the paper to academic research and industry practice?

Response

Result of this paper practically significant because damages to hospitals during disasters complicate relief measures due to delay in treatment of trauma and other diseases. Damaged hospitals also cause secondary disasters by compromising the achievement of national and global health goals, and by creating political risk for governments (Mani et al., 2016).

Result of this paper economically significant because of the economic and social costs associated with the damages to hospitals during disasters. Hospitals represent more than 70% of public spending on health in countries (World Health Organization, 2015). Studies on post major disasters found that damages to hospitals and health care facilities were estimated to be within a range of 61 to 214 days of government health spending on the entire population (International Strategy for Disaster Reduction, 2007). Population increase, climate change, and urbanisation are bound to worsen natural disasters in the future, thus resilient hospitals are an immediate necessity for Indonesia.

Hospital Safety Index is innovative in offering a new perspective on the disaster readiness of hospitals in Indonesia. It is critical that hospitals continue to work during emergencies and disasters since people immediately go to the nearest hospital for medical assistance when emergencies occur, without considering whether the facilities might not be functional. Consequently, it is vital to identify the level of safety and functionality a hospital will have if an emergency or disaster occurs. Hospital evaluations aim to identify elements that need improvement in a specific hospital or network of hospitals, and to prioritise interventions in hospitals that, because of their type or location, are essential for reducing the mortality, morbidity, disability and other social and economic costs associated with emergencies and disasters (World Health Organization, 2015). This is a crucial step in offering recommendations to strengthen the resiliency of health care facilities in Indonesia, which is a disaster-prone country.

Finally, when it comes to the limitations, authors should be transparent about the ways that the choices made during the study have limited the scope and reach of the findings. This can also open avenues for further research on the topic, and allow them to reflect upon how future endeavors can address the limitations of this work, but also how this work can offer opportunities for future research on the topic. These sections are currently considerably restricted in this paper.

Response:

This study has some limitations. Firstly, study was conducted during the situation of COVID-19 Pandemic, where hospital approval was is quite difficult. Therefore, it is required to collaborate with Ministry of Health and Hospital Organization in facilitating the licensing, not limited to government hospitals but also private hospitals. In addition, all the data collection was done through online or virtual methods. Secondly, the sample size is small, hence it can be more expanding for the hospital from various provinces with high-risk area towards disasters in order to analyse the difference preparedness levels among hospital’s in Indonesia by comparing the type of hospitals and their preparedness.  Moreover, long term research can be conducted by comparing the hospital preparedness and their real readiness when disaster occurs to assess the reliability of hospital safety index tool. Thirdly, the study was only focus on the elements of Hospital Safety Index published by WHO, hence another determinant contributed to the occurrence of disaster affected hospital was not examined. Further studies can be carried out by investigating determinant factors of hospital preparedness in Indonesia. 

 

 

 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

The paper was improved, but there are still comments that were not adequately attended, as listed below:

1) L. 134 It is necessary to present and define the risk index score and its range values, not only in the figures but also in the text.

2) texts within the figures are not legible

3) L. 203 What is the time interval (period) along which the research was conducted?

4) One of the main points in a scientific paper is the possibility of checking by third parties. In this sense, I believe it is necessary to make available the scores given for each item (or subitem) that compose the modules. Now the information is too compacted in the index´s black box, and the reader cannot understand how this crucial information was obtained. This can be done by creating a table as an Appendix (not Annex, but Appendix, since it is a product of the authors). That is, authors should present a table with the scores and description of the items (or subitems) that compose the disaster hazard and risk; structural safety (18items); non-structural safety (93 items); and emergency and disaster management (40 items). The table in Annex 1 does not show all the items (subitems); maybe this table can be enlarged.

5) In each module that composes the HSI, it is necessary to improve the conclusions and limitations of each risk category. In section 5, it is essential to analyze better the items that showed critical values (individual scores in C band).

6) When authors compare similar situations in different countries, explaining these similarities, contexts, and roots is necessary. That is, which conclusions may be applied to these similar cases, and which may not be? Why?

This happens when authors cite cases in Japan, Serbia, Croatia, Malaysia, Iraq, etc., that belong to very different contexts.

7) I think authors should dedicate more attention to COVID-19 (and other eventual pandemics/epidemics) and how it can affect the indexes and their meaning. For instance, is HSI still a helpful tool for hazards that occur under covid-19 restrictions? Do the HSI categories under COVID-19 restrictions remain the same? Or Category A may fall to Category B, B to C, etc., as much of the hospital capacity is blocked due to COVID demands? In Other words, how do covid 19 (and other pandemics/epidemics) restrictions affect HSI?

8) Many things that were added to section 6 should be in other sections, due to its general character (i. e., lines 634-363, 639-649, and others). Section 6 must be improved with key and relevant information to strengthen the conclusions, limitations, and recommendations.

8) There are still repeated sentences  (i.e., lines 262-273)

9) In line 378, why was it classified as Category A and not B since 0,642<0,65?  

10) North Sumatera or North Sumatra? Authors must adopt one option along with the entire text.

11) L.594 authors should reorganize section 6, since a subitem ‘6.1 Conclusion’ under a section ‘6. Conclusions’ is not appropriate.

12) There is a need for extensive revision in the English language, preferably by a native speaker. There are many problems with the nominal agreement, verbal agreement, punctuation, text fluidity, etc.

Author Response

RESPONSE TO REVIEWER 1

Thee paper was improved, but there are still comments that were not adequately attended, as listed below:

• 134 It is necessary to present and define the risk index score and its range values, not only in the figures but also in the text.

Response: Thank you for consideration. Therefore, according to risk classification as shown in Figure 1 (<13 categorized as low, 13-144 categorized as Medium, >144 categorized as high). 

• texts within the figures are not legible

Response: Thank you for your concern. We have tried to improve picture by translation into English, except the name of city. However we are struggling to revise since we just would like to show the disaster risk of each area with color green, yellow, or red.

• 203 What is the time interval (period) along which the research was conducted?

Response: The study was conducted during the period of April to October 2021.

• One of the main points in a scientific paper is the possibility of checking by third parties. In this sense, I believe it is necessary to make available the scores given for each item (or subitem) that compose the modules. Now the information is too compacted in the index´s black box, and the reader cannot understand how this crucial information was obtained. This can be done by creating a table as an Appendix (not Annex, but Appendix, since it is a product of the authors). That is, authors should present a table with the scores and description of the items (or subitems) that compose the disaster hazard and risk; structural safety (18items); non-structural safety (93 items); and emergency and disaster management (40 items). The table in Annex 1 does not show all the items (subitems); maybe this table can be enlarged.

Response: The table has been enlarged to accommodate the subitems, and it’s been placed as an Appendix 1 (see new table in Appendix 1).

• In each module that composes the HSI, it is necessary to improve the conclusions and limitations of each risk category. In section 5, it is essential to analyze better the items that showed critical values (individual scores in C band).

Response: it has been amended in Section 5.2. Structural safety:

“Result shown that several aspects within structural safety module have shown to obtain “C” band score, particularly in North Sumatera’s hospital such as sub-item prior major structural damage or failure of the hospital building(s), it means that the buildings have a prior major structural damage with no repairs. It is essential that this hospital need urgent improvement related to this structural safety, since it may endanger the workers, patients and public safety. Furthermore, result suggested that in North Sumatera’s hospital, several building integrity aspects including condition of construction materials due to rust with flaking, cracks larger than 3 mm (concrete) and excessive deformations (steel and wood) causing the level “C” band score. In order to protect the hospital from poor building integrity, this hospital should urgently repair this condition. Hospital in Yogyakarta shown similar aspect under building integrity which has “C” band score due to proximity of buildings (wind tunnel effect and fire) because of separation is less than 5 m and may create wind tunnel effect and fire spreads quickly.”

 

Response: it has been amended in Section 5.3. Non-Structural safety:

“Regarding aspects that have “C” band score, the hospital in Yogyakarta province should put special attention since several aspects contribute including due to external electrical systems installed for hospital usage, alternate water supply to the regular water supply. In DKI Jakarta, electrical system regular tests of alternate sources of electricity in critical areas is not conducted, so the score is become “C”. Hospitals in North Sumatera have several “C “ scores on emergency maintenance and restoration of standard and alternate communications systems; poor fire protection system including fire/smoke detection systems; fire suppression systems (automatic and manual); water supply for fire suppression; emergency maintenance and restoration of the fire protection system; poor fuel storage system; condition and safety of above-ground fuel tanks and/or cylinders; emergency maintenance and restoration of fuel reserves; poor medical system; availability of alternative sources of medical gases; emergency maintenance and restoration of medical gas systems; condition and safety of medical equipment in emergency care services unit; condition and safety of medical equipment for obstetric emergencies and neonatal care. Hospitals in Yogyakarta which have “C” band score are poor office and store room, safety of shelving and shelf contents; safety of computers and printers’ office and storeroom furnishings and equipment (fixed and movable); condition and safety of medical equipment and supplies for emergency care for burns.”

 

Response: it has been amended in Section 5.4.Disaster and Emergency Management:

“Elements in hospitals at North Sumatera that have “C” band score including coordination of emergency and disaster management activities such as hospital emergency/disaster committee; committee member responsibilities and training; designated emergency and disaster management coordinator; preparedness programme for strengthening emergency and disaster response and recovery; Emergency Operations Centre (EOC); coordination mechanisms and cooperative arrangements with local emergency/disaster management agencies. Indeed, other elements under hospital emergency and disaster response and recovery planning such as hospital emergency or disaster response plan; hospital hazard-specific subplans; procedures to activate and deactivate plans; hospital emergency and disaster response plan exercises, evaluation and corrective actions and hospital recovery plan. Other element which have “C” band score in North Sumatera including communication and information management such as emergency internal and external communication; external stakeholder directory and procedures for communicating with the public and media. Indeed, in North Sumatera hospitals which have “C” score is patient care and support services including continuity of emergency and critical care services. In Yogyakarta, element that has “C” score is financial resources for emergencies and disasters. “

• When authors compare similar situations in different countries, explaining these similarities, contexts, and roots is necessary. That is, which conclusions may be applied to these similar cases, and which may not be? Why?

Response: The comparison is only for highlighting the importance of specific elements such as fire protection, disaster and emergency management. It is not comparing situations which are definitely different in contexts and roots.

This happens when authors cite cases in Japan, Serbia, Croatia, Malaysia, Iraq, etc., that belong to very different contexts.

• I think authors should dedicate more attention to COVID-19 (and other eventual pandemics/epidemics) and how it can affect the indexes and their meaning. For instance, is HSI still a helpful tool for hazards that occur under covid-19 restrictions? Do the HSI categories under COVID-19 restrictions remain the same? Or Category A may fall to Category B, B to C, etc., as much of the hospital capacity is blocked due to COVID demands? In Other words, how do covid 19 (and other pandemics/epidemics) restrictions affect HSI?

Response:

Hospital Safety Index is developed before pandemic COVID-19, but it has address regarding biological hazards or infectious hazards in section “potential hazards”. Further research is needed to explore regarding Hospital  COVID-19 preparedness with more specific WHO Hospital COVID-19 preparedness guidance, and it cannot be compared in this current case with Hospital Safety Index.

• Many things that were added to section 6 should be in other sections, due to its general character (i. e., lines 634-363, 639-649, and others). Section 6 must be improved with key and relevant information to strengthen the conclusions, limitations, and recommendations.

Response: it has been updated accordingly

8) There are still repeated sentences  (i.e., lines 262-273)

Response: the double information has already deleted

9) In line 378, why was it classified as Category A and not B since 0,642<0,65?  

Response: We have already amended as your feedbacks.

10) North Sumatera or North Sumatra? Authors must adopt one option along with the entire text.

Response: We have already updated to the term North Sumatera

11) L.594 authors should reorganize section 6, since a subitem ‘6.1 Conclusion’ under a section ‘6. Conclusions’ is not appropriate.

Response: We have already updated.

12) There is a need for extensive revision in the English language, preferably by a native speaker. There are many problems with the nominal agreement, verbal agreement, punctuation, text fluidity, etc.

Response: thank you for suggestion

 

 

 

 

 

Author Response File: Author Response.pdf

Reviewer 3 Report

You did a good job. However, the main problem remains unresolved. You are analyzing a topical issue (Hospital Safety Index), but there is a lack of links to Sustainability throughout the analysis. If you do not have enough literature on this topic, you should write insights from yourself, both in the introduction, in the literature review and in the analysis of the results on how it relates to Sustainability, why it is relevant to your topic, and so on.

Author Response

RESPONSE TO REVIEWER 3

 

You did a good job. However, the main problem remains unresolved. You are analyzing a topical issue (Hospital Safety Index), but there is a lack of links to Sustainability throughout the analysis. If you do not have enough literature on this topic, you should write insights from yourself, both in the introduction, in the literature review and in the analysis of the results on how it relates to Sustainability, why it is relevant to your topic, and so on.

 

Response: Thank you for your advice, hence it helps us to improve the quality of paper. We added some information in introduction and discussion based on your recommendation as follow:

Introduction:

Hospital plays an important role in emergency situation. When hospitals fail in disaster and emergency situations, whether for structural or functional reasons, the result is the same: they are not available to treat the victims at precisely the moment they are most needed. Sendai Framework for Disaster Risk Reduction 2015-2030 has recognized the importance of making hospitals safe from disasters by ensuring that all new hospitals are built with a level of resilience that strengthens their capacity to remain functional in disaster situations and implement mitigation measures to reinforce existing health facilities, particularly those providing primary health care. When a hospital has a robustness, strength, and ability to recover from any disruptions or disaster, it will contribute directly to the achievement of the Sustainable Development.

Discussion:

The structural safety of hospitals in Yogyakarta and DKI Jakarta were in A level which indicates that it was built with proper design and construction, including the use of the principles of universal design and the standardization of building materials; retrofitting and rebuilding; nurturing a culture of maintenance; and taking into account economic, social, structural, technological and environmental impact assessments. Structural safety is very crucial for hospital resilience. When disaster occur, and hospital building remain safe, they can provide health care for the victims. Hospitals that are remain safe, resilient, and sustainable will contribute to the sustainability of health care. Hence, safe hospitals are also contributing in achieving sustainable cities and communities (SDG 11).

 

 

Author Response File: Author Response.pdf

Reviewer 4 Report

The manuscript has considerably been improved. Authors have revised all the sections of the paper based on the comments. However, minor revisions are required in order to improve the readability and presentation of the manuscript.

The Introduction is focused. Authors used the traditional structure in order to justify the research gap and the motivation as well as the value of this paper. Authors presented the motivation of the paper and discussed about the main findings. However, it is necessary to improve the theoretical and practical contribution of this paper.

The paper demonstrates an adequate understanding of the relevant literature in the field and an appropriate range of literature sources are used. Authors provided an overview of the results of the existing literature.

The research on which the paper is based is well designed and the methods that have been employed are appropriate. However, the authors should attempt to enhance the following: Is this section designed based on the existing literature? Please add references to justify the selection of the methodology.

Authors presented clearly the results of the analysis and clearly clarified limitations and suggestions for future research. The findings are a good basis for discussion.

Author Response

RESPONSE TO REVIEWER 4

The manuscript has considerably been improved. Authors have revised all the sections of the paper based on the comments. However, minor revisions are required in order to improve the readability and presentation of the manuscript.

The Introduction is focused. Authors used the traditional structure in order to justify the research gap and the motivation as well as the value of this paper. Authors presented the motivation of the paper and discussed about the main findings. However, it is necessary to improve the theoretical and practical contribution of this paper.

The paper demonstrates an adequate understanding of the relevant literature in the field and an appropriate range of literature sources are used. Authors provided an overview of the results of the existing literature.

Response:

Thank you for your feedback. It helps us to improve our manuscript.

The research on which the paper is based is well designed and the methods that have been employed are appropriate. However, the authors should attempt to enhance the following: Is this section designed based on the existing literature? Please add references to justify the selection of the methodology.

Response:

Thank you for the feedbacks, we have added the information below in methodology section.

According to WHO, the HSI is a rapid, reliable, and low-cost diagnostic tool that addresses the structural safety, non-structural safety and functional capacity of a hospital. This is a standardized tool to measure hospital preparedness through an assessment.[1].

While the HSI does not replace detailed vulnerability studies, it provides the decision makers with an overall idea of the hospitals’ ability to respond to major emergencies and disasters. In other words, an assessment using the HSI is the first step toward prioritizing a country’s investments in hospital safety. This helps the decision makers to prioritize the resource allocation [2].

Accreditation status may reflect the hospital preparedness because since January 2018, self-assessment for hospital disaster preparedness using HSI from WHO has become one of the components of the hospital accreditation in Indonesia.[3]

References:

[1] World Health Organization. Health facility seismic vulnerability evaluation. WHO/Euro. Copenhagen.2006.

 

[2] Barbera JA, Yeatts DJ, Macintyre AG. Challenge of hospital emergency  preparedness: analysis and recommendations. Disaster Med Public Health Prep2009; 3:74-82.

 

[3] Suparni, Fatma Lestari, Ede Surya Darmawan, Robiana Modjo, Senol Dane, Are Indonesian Hospitals Ready to Response to Disaster? Hospital Disaster Preparedness in West Java Province, J Res Med Dent Sci, 2020, 8 (4):89-93.

Authors presented clearly the results of the analysis and clearly clarified limitations and suggestions for future research. The findings are a good basis for discussion.

 

 

Author Response File: Author Response.pdf

Round 3

Reviewer 1 Report

The paper needs MINOR REVISION before being considered for publication.

- Figures´ texts are dificult to read and must be enlarged;

- There are still repeated paragraphs (lines 699 to 721, and lines 722 to 744);

- These paragraphs need English revision (“Results of this paper ARE...”).

Author Response

RESPONSE TO REVIEWER 1

The paper needs MINOR REVISION before being considered for publication.

- Figures´ texts are dificult to read and must be enlarged;

Response: it has updated accordingly

- There are still repeated paragraphs (lines 699 to 721, and lines 722 to 744);

Response: it has updated accordingly

- These paragraphs need English revision (“Results of this paper ARE...”).

Response: Our manuscript has already amended and reviewed by proof reader

 

 

 

 

Author Response File: Author Response.pdf

Reviewer 3 Report

In my opinion, the chapter conclusion, should not be with subsection, but should be single text, ending with the intended fyrther direction of research. 

Author Response

In my opinion, the chapter conclusion, should not be with subsection, but should be single text, ending with the intended fyrther direction of research. 

Response: Thank you, it has updated accordingly

Author Response File: Author Response.pdf