The Application of Hospital Safety Index for Analyzing Primary Healthcare Center (PHC) Disaster and Emergency Preparedness

Round 1

Reviewer 1 Report

The paper is interesting for its implications on the operation of hospital complexes during pandemics. It misses relevant recent literature referencing, some comparison with real hospital response during disasters and some concept of prioritization that can be made with a level "0" tool like the WHO/PAHO safety index is. A revision is needed

Detailed comments are reported in the attached pdf

Comments for author File: Comments.pdf

Author Response

Reviewer 1

The following revision has been made as per reviewer’s comment and amended in the revised paper.

Comments and Suggestions for Authors

The paper is interesting for its implications on the operation of hospital complexes during pandemics. It misses relevant recent literature referencing, some comparison with real hospital response during disasters and some concept of prioritization that can be made with a level "0" tool like the WHO/PAHO safety index is. A revision is needed

Response:

Thank you for the feedback. We have already added according to your comments

The assessment of hospital emergency preparedness is important in order to elucidate weaknesses in the hospital disaster plan and to guarantee effective hospital functions during disasters [29,30]. Assessment methods and checklists have been created by researchers and authorities [29,31–34]. However, there is no consensus on a both valid and reliable tool with which to measure hospital preparedness [30,33–35]. Moreover, most countries tend to use their own assessment tools [31–33,35]. Currently, Indonesia utilize Hospital Safety Index (HIS) issued by WHO/PAHO to determine hospital preparedness for disaster, and it is also used in the assessment of hospital accreditation in the National Hospital Accreditation Standard (SNAR). The researcher believe that using an International, validated tool such as HIS [24] is beneficial and allowing for standardized comparisons.

Detailed comments are reported in the attached pdf

Introduction misses previous relevant research on the hospital disaster emergency management and to the application of the WHO/PAHo safety index as well, which should considered

 

Aiello A, Pecce M, Di Sarno L, Perrone D, Rossi F (2012) A safety index for hospital buildings. Disaster Adv 5(4):270

Santarsiero G, Di Sarno L., Giovinazzi S., Masi A., Cosenza E., Biondi S. (2018) Performance of the healthcare facilities during the 2016–2017 central italy seismic sequence. Bulletin Of Earthquake Engineering, ISSN: 1570-761X, doi: https://doi.org/10.1007/s1051

2017. Masi, L. Chiauzzi, G. Santarsiero, M. Liuzzi & V. Tramutoli (2017). Seismic damage recognition based on field survey and remote sensing: general remarks and examples from the 2016 Central Italy earthquake. Nat Hazards, 2017. DOI 10.1007/s11069-017-2776-8.
2018. Masi, G. Santarsiero, L. Chiauzzi (2014). Development of a seismic risk mitigation methodology for public buildings applied to the hospitals of Basilicata region (Southern Italy). Soil Dynamics and Earthquake Engineering. Volume 65, Pages 30-42.
2019. Masi, G. Santarsiero, M.R. Gallipoli, M. Mucciarelli, V. Manfredi, A. Dusi, T. A. Stabile (2013). Performance of the health facilities during the 2012 Emilia (Italy) earthquake and analysis of the Mirandola hospital case study, Bulletin of Earthquake Engineering. DOI: 10.1007/s10518-013-9518-4

 

Response:

Thank you. We revised it as your references provided

 

In addition, the procedure of seismic risk mitigation strategy is based on a global risk index involving the entire building stock under study thus facilitating an examination of risk variation over time up to its final value [24]. In all the surveyed hospitals there were partially or totally unusable buildings causing severe limitations to the functionality of the healthcare services, forcing to move many patients to other hospitals and to stop outpatient treatment. This was due mainly to severe damage to non-structural components and, in some cases, to moderate damage to structural components [25]. A short description of the damage suffered and characteristics of the healthcare system as a whole is offered initially, followed by a detailed description of the effects which took place at the Santa Maria Bianca hospital of Mirandola. The focus has been on damage to non-structural elements and content, whose integrity is of primary importance for healthcare structures performance during and after a seismic event [26}. Pan American Health Organization (PAHO) and World Health Organization (WHO), finally provides a safety index as function of all the parameters that characterize the seismic risk: vulnerability, hazard and exposition [27].

 

double dot

A total of 15 mixed natural and 228 non-natural disasters (COVID-19 pandemics) occurred in this province in 2020.. (Ading)

Response:

Thank you for the correction. It has been revised

PHC are not described at all. None of the following data is reported: no. of beds, no. of buildings, material (masonry, RC, steel...), behavioru in past events.

 

 

 

 

Response:

 

World Health Organization (WHO) defines Primary Healthcare Center (PHC) as a whole-of-society approach to health that aims at ensuring the highest possible level of health and well-being and their equitable distribution by focusing on people’s needs and as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people’s everyday environment.

Introduction

Protecting the lives of people affected by a disaster or emergency immediately after the event strikes is essential. Health services, including those provided by the Primary Healthcare Center (PHC). PHC is a healthcare service facility that organizes public health apparoach and first-level individual health efforts, by priotizing promotive and preventive actions in its working area [1].

Research conducted in 4 (four) provinces in Indonesia: North Sumatera, DKI Jakarta, West Java and Special Provinces of Yogyakarta. Sample were selected using purposive sampling technique. PHCs were selected based on the most susceptible and vulnerable locations. These are the data of 11 (eleven) selected PHCs for this study:

 

Table 1. 11 PHC Information

Province	PHC name	Types of PHCs	Number of Buildings	Number of Bed
Sumatera Utara	PHC A	Puskesmas rawat inap (PHC in-care patient)	1	5
	PHC B	Puskesmas rawat inap (PHC in-care patient)	1	8
	PHC C	Puskesmas rawat inap (PHC in-care patient)	1	4
DKI Jakarta	PHC D	Puskesmas rawat inap (PHC in-care patient)	1	10
	PHC E	Puskesmas rawat inap (PHC in-care patient)	1	10
Jawa Barat	PHC F	Puskesmas rawat inap (PHC in-care patient)	2	15
	PHC G	Puskesmas rawat inap (PHC in-care patient)	5	23
	PHC H	Puskesmas rawat inap (PHC in-care patient)	2	22
Daerah Istimewa Yogyakarta	PHC I	Puskesmas rawat inap (PHC in-care patient)	2	10
	PHC J	Puskesmas non rawat inap (PHC outpatient services)	1	-
	PHC K	Puskesmas non rawat inap (PHC outpatient services)	1	-

 

this lines are not visible in fig 2 (……) (…….)

 

in this regard the references suggested for the introduction are useful also here.

 

Response:

We have already updated for figure 2.

 

Previous studies demonstrate that for structural/seismic safety the PAHO index is useful as relative comparison among several hospitals. It is useful to prioritize interventions and not for an absolute evaluation which requires a detailed assessment.

 

Santarsiero, G., Di Sarno, L., Giovinazzi, S. et al. Performance of the healthcare facilities during the 2016–2017 Central Italy seismic sequence. Bull Earthquake Eng 17, 5701–5727 (2019). https://doi.org/10.1007/s10518-018-0330-z

 

Response:

We have updated as your recommendation.

Evaluation results for structural safety is useful for prioritizing structural renovation and reconstruction. Indeed, building structural requirement should be in compliance to the ministry of Health No. 43 Year 2019 about Primary Healthcare [1], Indonesia Law Act no No.28 Year 2002, and Government Regulation No 16 Year 2021 about Buildings [50,51] which stated the requirements for PHCs to be built as an earthquake resistant buildings. Result from this study can provided best solutions for local government and Indonesia ministry of health for future improvement particularly for PHCs buildings. The objectives for this compliance to building structural requirement are ensuring that PHCs can continuously deliver healthcare services during and post-disasters.

Previous research has shown that the PAHO index can be used to compare the structural/seismic safety of different hospitals. It's effective for prioritizing treatments rather than an absolute appraisal, which necessitates a thorough examination [25]. Hospital Safety Index (HSI) is commonly used to assess hospital resiliency for various types of emergencies and disasters [23]. Hospital resiliency during emergencies and disasters can also be measured using Hospital Emergency and Disaster Management Index using TOPSIS Method [10].

 

Among the recommendations, this reviewer would indicate that this is a preliminary screening able to provide insight on the major urgencies, i.e. the first PHCs to be interested by further analysis. 

 

Response:

 

Thank you for the feedback. We added that information in recommendation section. This present study is a preliminary screening which are able to provide an insight on the major urgencies such primary health care. Therefore, further analysis and investigation need to be conducted in other areas.

 

Author Response File: Author Response.pdf

Reviewer 2 Report

The paper is interesting and addresses a hot topic in disaster management. It is well-written. I believe it can be considered for publication after addressing some issues, one of them is the lack of sufficient literature review.

The title is a bit confusing and unclear. it should be revised.

Maybe starting the abstract with “Primary Healthcare Center (PHC)” is a bit unclear for a reader with basic knowledge about health and disaster management. Therefore, I suggest a sentence with plan language should be added before this sentence to briefly state what “Primary Healthcare Center (PHC)” is.

Line 24 and 25 only were used for the name of an organization? Please make the abstract more concise. All in all, I suggest the structure of the abstract should be more punchy!

Although there are many similar studies in the literature, the authors ignore them. A section should be 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.

The presentation of all tables, particularly table 1 should be improved.

furthermore, the data collection should be explained more clearlly.

Author Response

 

Reviewer 2

Comments and Suggestions for Authors

The paper is interesting and addresses a hot topic in disaster management. It is well-written. I believe it can be considered for publication after addressing some issues, one of them is the lack of sufficient literature review.

Response: Thank you for great comments. It helps for better manuscript.

The title is a bit confusing and unclear. it should be revised.

Response:

The title has been revised accordingly:

The Application of Hospital Safety Index for Analyzing Primary Healthcare Center (PHC) Disaster and Emergency Preparedness

Maybe starting the abstract with “Primary Healthcare Center (PHC)” is a bit unclear for a reader with basic knowledge about health and disaster management. Therefore, I suggest a sentence with plan language should be added before this sentence to briefly state what “Primary Healthcare Center (PHC)” is

Line 24 and 25 only were used for the name of an organization? Please make the abstract more concise. All in all, I suggest the structure of the abstract should be more punchy!

Response: We revised these sections. Definition has been made based on WHO definition and Indonesia Ministry of Health No. 43 Year 2019 about PHC.

World Health Organization (WHO) defines Primary Healthcare Center (PHC) as a whole-of-society approach to health that aims at ensuring the highest possible level of health and well-being and their equitable distribution by focusing on people’s needs and as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people’s everyday environment. PHC are expected to remain operational when disasters occur. This study aimed to assess PHC disaster preparedness level in Indonesia using The Hospital Safety Index (HSI) from WHO/PAHO. Eleven PHCs located in four provinces in Indonesia, i.e., Jakarta, Yogyakarta, North Sumatera, and West Java, were selected. Data were collected through interviews, focus group discussions (FGDs), observations, and document reviews. Parameters assessed were all types of hazards, structural or construction safety, nonstructural safety, and functional attributes. The results show that the overall score of HSI for PHCs in Jakarta (0.674) and North Sumatera (0.752) fell into the “A” category, meaning that these PHCs would likely to remain operational in the case of disasters. Meanwhile, the overall HSI scores for PHCs in West Java (0.601) and Yogyakarta (0.602) were between 0.36 and 0.65, or in “B” category, meaning that these PHCs would be able to recover during disasters but several services would be exposed to danger. Result suggested that there are several gaps which need urgent interventions to be applied for building structural safety, water supply system, fuel storage, disaster committee organization, furniture and fittings, offices and storage equipment, as well as increasing capacity of workers through a structured and systematic training framework for disaster readiness. Results from this study can be used for prioritizing budget and resource allocation, cost planning, providing specific solutions for local and national government and effort to disaster risk reduction.

Although there are many similar studies in the literature, the authors ignore them. A section should be added to this paper and recent studies should be addressed and critically analysed, for example:

Response: It has been amended on the discussion section, as per reviewer’s comments by including the following references:

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.

 

Thank you for feedback. We have updated as follow.

On introduction: Healthcare facilities plays important role during disaster situation in order to save life and providing healthcare services for the communities impacted by disasters. Healthcare facilities are expected to stay fully functional during and immediately after the disaster strikes. Therefore, it is highly important to conduct evaluation of PHCs emergency and disaster preparedness.  There are several elements that can be used to evaluate the emergency and disaster preparedness in healthcare facilities [10]. Mojtahedi et al (2021) [10] evaluate disaster preparedness by using element: emergency and disaster management coordination, response and disaster recovery planning, communication and information management, logistics and evacuation, human resources, finance, patient care and support services, decontamination and security. While Yazdani et al (2021) [11], focus on evaluating the disaster readiness on plannig and patient evacuation.  On the other hand, Aghapour (2019) [12], highlight the importance of expanding the hospital's room, increasing surge capacity for disaster management.

 

Major changes have been made in most of Discussion sections.

Indonesia is a disaster-vulnerable nation; it is located in a dangerous area where almost 90% of the globe’s earthquakes happen in this region. Indeed, Indonesia is the place where 15% of the earth’s active volcanoes, making the existence of earthquakes, volcanic eruptions, and tsunamis are more frequent [58, 59]. Hence, this high-risk situation making the structural safety element in HSI has become the most important element for hospital readiness in facing emergencies and disasters. Many health care facilities including primary health care have been damaged during Lombok’s and Palu’s earthquakes due to incompliance with structural safety [60, 61].

 

Evaluation results for structural safety is useful for prioritizing structural renovation and reconstruction. Indeed, building structural requirement should be in compliance to the ministry of Health No. 43 Year 2019 about Primary Healthcare [1], Indonesia Law Act no No.28 Year 2002, and Government Regulation No 16 Year 2021 about Buildings [50,51] which stated the requirements for PHCs to be built as an earthquake resistant buildings. Result from this study can provided best solutions for local government and Indonesia ministry of health for future improvement particularly for PHCs buildings. The objectives for this compliance to building structural requirement are ensuring that PHCs can continuously deliver healthcare services during and post-disasters.

Previous research has shown that the PAHO index can be used to compare the structural/seismic safety of different hospitals. It's effective for prioritizing treatments rather than an absolute appraisal, which necessitates a thorough examination [25]. Hospital Safety Index (HSI) is commonly used to assess hospital resiliency for various types of emergencies and disasters [23]. Hospital resiliency during emergencies and disasters can also be measured using Hospital Emergency and Disaster Management Index using TOPSIS Method [10].

4.3 Non-structural Safety

Non-structural safety is a key factor for healthcare to continue remain operational in case of electrical blackout. Java Island at which DKI Jakarta, West Java and Yogyakarta are located, have experienced massive blackout during 2019 [62]. The blackout ceased after unusual long period of electrical blackout for 2 days in a certain area, while remain blackout for 3 days period for other areas. This situation has learned the healthcare facilities to be more prepared in case the similar electrical blackout occurs. Healthcare facilities need to be ready for up to 3 days without electricity by preparing several methods to remain operational, including fuel storage and electricity back-up.

4.4 Functional Aspect

The most recurring areas of extreme events and disasters occurrence are located in Java and Sumatra Island [63]. There are 5 (five) provinces in Indonesia have been considered as high disaster prone areas based on extreme events and disasters frequencies which has consequences on human health: Central Java, DKI Jakarta, West Java, East Java and North Sumatra [63]. The readiness of healthcare in facing various types of extreme events and disasters deemed to be important particularly the readiness of disaster committee and its capacity to conduct evacuation [11,12].

The result of the functional aspect assessment demonstrated that this aspect obtains the lowest score compared to the other two aspects. It is revealed that, of the 11 PHCs of the study area, only one PHC was in the “A” category, whereas the other 10 PHCs were in either category “B” or “C”. The PHC in category “C” is located in West Java Province. One of the assessment items for this functional aspect is the availability of PHC’s Emergency/Disaster Committee. From the overall assessment carried out, the PHCs located in Yogyakarta Province already have a formally established PHC’s Emergency/Disaster Committee, which is run by the PHC’s management staff. The importance of PHCs’ disaster committee organizations have been indicated from other research [55], at which PHC’s disaster committee could implement the disaster management in case of emergencies or disasters [55].

The experience of a major disaster that occurred several years ago in Yogyakarta Province has increased the awareness for improvement. What needs to be considered from this aspect assessment is that many PHCs do not have yet an emergency response plan or emergency response training for personnel. Emergency response plan is one of the key factors in disaster risk reduction particularly minimizing the impact of disasters to patients, visitors and workers [10,11,12]. Without good emergency response plan, PHCs patients, visitors and workers are at high risk during emergencies and disasters situation [10,11,12].

Personnel training is often an issue in implementing emergency and disaster management. This is in line with other research on PHCs in Iran, where the HSI index for training and training personnel aspect is considerably low [54]. The results of the MCA also show that from all aspects of the assessment using the HSI instrument, the PHCs in all assessment provinces tended to be closer to category “B” and required improvement. PHCs need to prioritize an effort to fulfill these functional aspects to reduce the risks to PHC’s patients, workers and visitors.

 

The presentation of all tables, particularly table 1 should be improved.

Response:

Thank you. In order to provide a clear information regarding table 1. We revised it into a paragraph  in the section 2 point 2.2

furthermore, the data collection should be explained more clearly.

Response: we added it on section 2.1 study location, sampling, and data collection

The sampling method applied in this study is the non-probabilistic purposive sampling. The PHCs were chosen based on the analysis of study objectives as well as the agreement with local health authorities. Eleven (11) PHCs participated in the study: two (2) were in Jakarta (capital city of Indonesia), three (3) in West Java, three (3) in Yogyakarta, and three (3) in North Sumatera.

HSI recommends to use combined method of data collection: document review, indepth interview, focus group discussion and systematic observations [41]. Data collection was performed by a group of four surveyors and evaluators, including a disaster management expert, a nurse, a public health officer, and a civil engineer who are experts in hospital disaster management. Data were collected in four months because the surveyors and evaluators needed at least four days to collect data from a PHC during this extreme pandemic situation, as well as due to the complexity of the HSI data collection. An information session was held with each PHC to inform about the research. Further, In-depth structured interview then conducted with selected key informants from each PHC that could answer questions about potential hazard and disaster risk, structural and also nonstructural aspect of HSI. After that, observations on the PHCs were conducted through offline and virtual video conference.  Focus Group Discussion (FGD) that involved the PHC’s heads, administrative personnel, emergency responders, building services and electrical maintenance personnel, and public health officers was also conducted to gather the group perspective on the HSI condition in the facilities. Additionally, document review was performed to review the existing measured. The quantitative data collection was conducted to determine the PHC disaster preparedness level using the WHO/PAHO Guidelines Evaluation of Small & Medium-Sized Health Facilities, 4th edition (2015) [41].

 

 

Author Response File: Author Response.pdf

Reviewer 3 Report

Suggestions:

1. Poor statistical analysis. Needed more analysis with explanations for the tables. Especially it is unclear who the ratio is calcuated, what it is meaning (explaination), why it is used the total score for modules (References). There is any other alternatives? 
2. In table 3 who the indes is calcuated and what the values is meaning
3. Explanation of the Table 5. Analysis of a, total eigenvalue, inertia, % of variance. Definitions and analysis.

Author Response

Reviewer 3

Comments and Suggestions for Authors

Suggestions:

1. Poor statistical analysis. Needed more analysis with explanations for the tables. Especially it is unclear who the ratio is calcuated, what it is meaning (explaination), why it is used the total score for modules (References). There is any other alternatives? 

Response: Thank you for kind feedback

Descriptive statistics were performed through the measurement of central tendency were used for the value of structural, nonstructural and functional aspect. The distribution of the value of structural, nonstructural and functional aspect was tested by the normality.

Further analysis was then conducted using the multiple correspondence analysis (MCA) to describe the correlation mapping between the variables of the disaster preparedness level or HSI (dimension 1) and provinces under study (dimension 2). The MCA was applied to identify and characterize the basic pattern within the data [5,43]. The MCA permits a scientist to investigate the relationship configuration derived from some 206 categorical dependent variables and is used to study a set of observations, which are explained by a group of nominal variables [4,28]. In this research, the MCA was conducted using the SPSS software version 25.0 to create the map.

 

2. In table 3 how the indexes is calculated and what the values is meaning

 

Response:

Table 3 Overall Hospital Safety Index

No	Module	Weight	Ratio	Index
1	Structural Safety	50	0.688	0.344
2	Non-structural Safety	30	0.694	0.208
3	Functional Aspects	20	0.449	0.090
Overall Hospital Safety Index				0.642

 

Table 3 demonstrates that the overall safety index for all samples in all provinces was 0.642. It was interpreted that the hospitals in this study were classified in the category B (HSI 0.36–0.65), which means that intervention actions are needed in the short-term. From the perspective of the PHC’s level of safety, emergency and disaster management that includes the safety of workers and patients and the ability of each PHCs to fully function during and post emergencies and disasters, these aspects were possibly at risk during and post emergencies and during disasters. The calculation of each hospital’s safety index is based on the weighting of the respective modules. 
The values for structural components represent 50% of total values in the index, nonstructural components represent 30%, and functional capacity represents 20%. This model is proposed for countries or regions where there is a higher risk of structural and nonstructural failure, as in high earthquake-prone or high-wind areas like at North Sumatera, Jakarta, West Java and Yogyakarta. The index part was calculated by multiplying the weight with the weighting ratio of each module.

 

3. Explanation of the Table 5. Analysis of a, total eigenvalue, inertia, % of variance. Definitions and analysis.

 

Response:

 

It has been added according your feedback in below figure 2

 

Eigenvalues depicts the relative relevance of each dimension to the total inertia (it is normalized to 1 which stand for all the information of all the variables in the dimensions). The highest eigenvalue was always in the first dimension, progressively decreasing across the following dimensions. Inertia which illustrates the dispersion of data and which is considered as a measure of information of data. This variable (together with the total inertia) is commonly used to select the maximum number of dimensions to be included in the MCA map and analysis. Thus, dimensions with an eigenvalue lower than 0.05 are usually not considered. Based on the table above, eigenvalues are more than 1, which means that the dimensions are considered. The total variance percentage for each dimension is explained by the inertia (eigenvalue). Dimension 1 has an inertia value of 0.662, meaning that the variance of the indicator matrix for the first dimension is 0.662 (66,151%). While the value of inertia dimension 2 is 0.342 (34.2%). The value of the proportion of inertia shows the proportion of the main inertia of the indicator matrix to the total inertia.

 

 

 

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

The current version is acceptable 

Reviewer 3 Report

The authors have done a lot of improvements