Emergency Hospital Service Delivery - JPRM 2011 - Final Report - English

Hospital Hospital Hospital Hospital

Disaster Disaster Disaster Disaster

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Iranian Iranian Iranian Iranian

HospitalsHospitalsHospitalsHospitals

The Road Ahead For Iranian Hospitals Momeni A., Yousefi E. December 2011

APW for developing SOP for hospital emergency service delivery – Third Deliverable - English Page 2

APW for developing SOP for hospital emergency service delivery

Final Report

December 2011

Amir Momeni MD.

EHMTP Director

Principal Investigator

Elham Yousefi MD.

Technical Officer

World Health Organization

&

Ministry of Health and Medical Education of Islamic Republic of Iran

JPRM 2010-2011

©WHO/EMRO, December 2011



Acknowledgements:

We thank the staff of the Secretariat for Health Risk Management in Disasters of MOHME, especially

Dr. Gholamreza Masoumi without whose support and cooperation this project could not have been

completed. We must also stress our gratitude for members of EHMTP for their excellent field work.

Last but not least we must thank the staff of WHO’s Iranian office, especially Dr. Manuel Torres and

Ms. Laleh Najafizadeh, whose technical insight and guidance have greatly improved the quality of this

project.



Abbreviations:

WHO – World Health Organization

MOHME – Ministry of Health and Medical Education of Islamic Republic of Iran

EHMTP – Emergency Health Management Training Program

CHRMS – Comprehensive Hospital Risk Management System

EMS – Emergency Medical Services

HEICS – Hospital Emergency Incident Command System

NHPP – National Health Preparedness Plan



Introduction:

This is the final report of the JPRM 2010/2011 project entitled “APW for developing SOP for hospital

emergency service delivery” which is being completed with collaboration of world health organization

and ministry of health and medical education of Islamic Republic of Iran. We will outline the project,

the results and methodology and point out the main challenges ahead. In this report we propose an

implementation strategy as well as describing the best way for integrating the results of this project

into the National Health Preparedness Plan (NHPP). For any inquiries regarding this project or the

findings presented please contact me by email: [email protected]

` Amir Momeni MD,

Project Manager

December 2011



Table of Contents Executive Summary: ...................................................................................................................................................... 7

Methodology: ................................................................................................................................................................ 8

Comprehensive Hospital Risk Management System: .................................................................................................. 11

Hospital Disaster Plan: ................................................................................................................................................ 13

Integration into NHPP: ................................................................................................................................................ 15

The Road Ahead: ......................................................................................................................................................... 17



Executive Summary: Hospital emergency plans form the core of the second �er of the health system in response to

disasters and emergency situa�ons. The first �er are efforts at the disaster field and the second

�er is mainly about delivering defini�ve care and con�nua�on of health services, to this end

hospitals play a very important role. The third �er is composed of efforts at na�onal and

regional levels including mobiliza�on, governance and oversight. The hospital disaster plans can

follow a generic framework; mainly because organiza�on and design of hospitals around the

country is generally similar and secondly because irrespec�ve of condi�ons every hospital faces

a set of predetermined hazards and emergency situa�ons. As a result designing the framework

as we have done in this project can act as the stepping stone for na�onwide implementa�on of

hospital disaster plans.

In our framework, the hazards faced by hospitals are categorized in two main sets; the first are

internal disasters where the hospital itself and its inhabitants are directly threatened, the

second are external disasters in which the community that the hospital serves is threatened

and the hospital needs to receive an influx of pa�ents and casual�es. These two categories

while significantly different can (and usually will) co-occur requiring the hospital disaster plans

for them to be compa�ble.

Hospital disaster plan has three separate levels; the first level is hospital mi�ga�on plan, the

second being the hospital preparedness plan and finally the hospital response plan. The

mi�ga�on plan is mainly about risk and vulnerability reduc�on. The preparedness plan is about

developing capacity and capabili�es as well as designing the response plan; the response plan

are the emergency func�ons and measures that need to be implemented in the event of a

disaster. This project provides a framework for hospital disaster plans as well as providing a

generic guideline on procedures related to emergency response.

The results of this project need to be complemented by generic guidelines on risk reduc�on and

preparedness in order to make a comprehensive generic hospital disaster plan which can be

then adopted into the NHPP. In this final report while outlining the results of this project we

have also provided a strategic outline for assimila�ng these results into the NHPP and country

wide implementa�on of the principles of hospital disaster management.



Methodology: This is the final report in a series of three developed for the JPRM 2011 project “APW for

developing SOP for hospital emergency service delivery”.

The first task for the first report was evidence review. For this a comprehensive search of all

available evidence online was performed. In this search free databases including Google

Scholar, Medline, WHO libraries, Indexmedicus and others were searched for prac�ces and

guidelines on hospital disaster response planning. A separate search was conducted on Google

for all documented hospital disaster plans from around the world. The neighbouring countries

were chosen as the benchmarks for Iran and a country specific search for hospital preparedness

and response was conducted as well. The results were skimmed and all useful documents and

resources were selected. The documents were categorized as policy documents, technical

documents and case studies. In each category further thema�c and subject based

categoriza�on was made. A9er documents were assigned to their categories, they were rated

based on content, reliability and relevancy. Project members then thoroughly reviewed and

summarized the evidence that was highly rated in the previous sec�on and a series of mee�ngs

were held during which the topics of the project were discussed and each member contributed

to the topic based on the evidence she/he had reviewed. The end result was developed in two

different categories, the first was background and ra�onale which is presented in this report

and the second category was best prac�ces which will be used in developing the generic plans

in the second and third report. The evidence that contributed to the conclusions drawn were

listed as the references.

The second task was situa�on analysis. This was a field work for which a task force was chosen

from the project members and were trained in conduc�ng objec�ve based interviews. A

ques�onnaire was developed as well which assessed the basic level of preparedness in

hospitals. The task force conducted interviews based on the designed ques�onnaire with

hospital representa�ves and the results that were obtained were summarized and in some

cases quan�fied. As a part of this task, the MOHME was asked to provide a report on all policies

and regula�ons related to hospital disaster management and emergency health management

as well as any experience or related project. The report was provided and evaluated; in

evalua�on all items which did not have enough suppor�ng documenta�on were omi<ed. The

end results were discussed in a series of sessions and weaknesses as well as strength of the

current situa�on and conclusion as to what needs to be done, were determined. The situa�on

analysis has since been updated with more hospitals country wide being assessed for their level



of preparedness; while there were differences between regions especially in areas such as

awareness and preliminary planning; s�ll there is no�ceable lack of systemic disaster planning

at hospitals country wide.

The third task was developing a framework and outline upon which to proceed, it was agreed

that the outline needs to address both internal and external disasters and be generic so that it

can be adopted and used in hospitals around the country. Through a series of sessions the

outline was developed and is presented in this report.

The results were summarized and the first report was dra9ed. A knowledge base was also

created from all of the references.

For the second deliverable of the project, an outline of the CHRMS in internal disasters was

established using focused discussion sessions of the par�cipa�ng members. Using the results of

the first deliverable as well as the knowledge base and by going through the best prac�ces from

around the world the framework for response to internal disasters was established. This

framework is provided in the first sec�on of the Persian version of the second report as well as

the English report. An expert plan was then consulted and their inputs regarding the framework

were gathered and the framework was modified accordingly.

Then based on the hazard analysis reports from previous projects and based on the inputs of

the expert panel, the most common hazards faced by hospitals in Iran were chosen and to each

a team was assigned. Each team developed a generic response plan based on the framework

developed earlier that can be used in hospitals around Iran. As the generic plans were designed

for Iranian hospitals, the plans are only in Persian and available in the second sec�on of the

Persian report.

An explanatory so9ware, in form of a presenta�on that can be used both as a teaching material

as well as a self-learning tool was then prepared. The findings were then summarized and an

English report containing the framework for internal disaster response and a Persian report

containing the framework as well as generic plans for fire emergencies, earthquakes, radiologic

events, chemical events, epidemics, isola�on and evacua�on were wri<en.

For the third report, the experiences of previous external disasters on hospitals around the

country were examined. While many hospitals have had experiences with mass casualty

management only a few documented cases were available. These case studies showed that

while the efforts have been par�ally successful, a general and organized approach to the issue

is missing. There is however a great deal of experience on the use of field hospitals in Iran, not



only a guideline was developed by the MOHME as part of the emergency health func�ons

project but also the experiences from the 8 years war with Iraq as well as the many disasters

that have occurred in Iran has led to a high level of exper�se on the ma<er in the country and

as field hospitals can play a role in surge capacity planning we feel that the available guidelines

on the ma<er can form the basis for a more prac�cal protocol to be developed. The issue of

surge capacity planning has not been addressed so far in the country; as a result this report

provides a summary of the best evidence available for the subject ma<er.

For this final report we looked at policies adopted worldwide for integra�ng hospital disaster

management and CHRMS into the na�onal preparedness plans as well as general policies

governing the issue of hospital disaster management and response. Our findings showed that

successful hospital disaster management plans follow a decentralized approach in which

general guidance and policies are set by an overseeing governing body (e.g. JCAHO) and are

then adopted and implemented at the hospital level based on local condi�ons. However the

Iranian health system is much more centralized, with main decisions being made at ministerial

level and secondary decisions being made at medical university level essen�ally leaving out

hospital managers from policy and strategy decisions. Through a series of focused discussion

sessions between experts as well as through ground level interviews with hospital managers we

have developed a strategy outline which allows for both centralized decision making of the

Iranian health system while providing enough flexibility at the hospital level. In this framework

the governing body will provide policies, strategic plans, technical and financial support as well

as measurement and evalua�on. The hospital will then in accordance with the outlines set at

the higher levels design their own hospital disaster plans. In other words we have proposed

that hospitals design plans that fit the framework provided to them partly through the results

of this and similar projects.

We have ended the report with challenges ahead as well necessary steps that we think are

necessary in order to develop a complete set of guidelines for the second �er of NHPP.



ComprehensiveHospitalRiskManagementSystem:

Hospitals need a risk management system; risk management goes further than dealing with

disasters, it is in essence a safety system which assures that the health of the inhabitants of the

hospital, be it a pa�ent or a staff member, is not threatened because of their physical presence

in the hospital. The emphasis on the comprehensiveness of the system is to address every risk

involved. The risks form a spectrum of intensity; on one end there are trivial risks such as noisy

environment, a bit more serious are risks such as medical mistakes and then on the other end

of the spectrum are disasters. Hospitals need to address all of them; the risks on the low

intensity head of the spectrum s�ll pose a significant cumula�ve threat to health, while on the

other hand a single event such as an earthquake can completely devastate the hospital.

CHRMS in mainly a decision support system, it allows the hospital administrators to choose

which risks to address and how to address them, the criteria used for choosing risks includes

elements such as intensity, impact, probability, frequency, cost and cost benefit analysis. The

CHRMS allows based on the standards set by the governing bodies to define acceptable level of

risk and prompt decision makers to address the unacceptable risk. Figure 1 shows the spectrum

of risks and their distribu�on based on different criteria.

Figure 1: Risk Spectrum



CHRMS starts with risk analysis and resource organiza�on; level of acceptable risk is not only by

the threats and hazards but also by the resources available to avert them as a result the very

first step is to determine what and what quan�ty of resources can be allocated to the risk

management. This is then followed by risk analysis which includes hazard analysis, vulnerability

capacity analysis and risk mapping (the process of risk analysis is outlined in a previous JPRM

project supervised by our team – Risk Reduc�on Strategies, JPRM 2008-2009). The process is

followed by diagnos�c journey, which is similar to root cause analysis; the roots of the threat

are iden�fied and subsequently addressed in policy and strategy development. A decision must

be made on which of the strategies and policies that were developed to be implemented and

then implementa�on can begin, with periodic evalua�ons as well as end point measurements.

There are some func�ons that should be con�nuous throughout the cycle for example

documenta�on and monitoring are applicable to every step. Figure 2 provides an outline of the

CHRMS cycle.

Figure 2: CHRMS cycle



Hospital disaster planning forms an important part of CHRMS; it addresses high impact events

such as fires, earthquakes and etc. We started this report with CHRMS to show that hospital

disaster management should be addressed as a part of a bigger push towards safety and safe

hospitals. An integrated system for risk management allows for be<er resource alloca�on as

well as greater cost effec�veness. However as the goal of the project was on hospital

emergency response plan we have focused on hospital disaster plans especially disaster

response.

Hospital Disaster Plan:

The hospital disaster plan is divided into three levels; these levels are actually defined based on

the disaster �meframe; efforts done far before the disaster with the aim of aver�ng it all

together form the first level (disaster mi�ga�on plan). The mi�ga�on plan includes risk and

vulnerability reduc�on, retrofiBng, reloca�ng and etc. The second level is hospital

preparedness planning which aims to develop capaci�es and capabili�es to lessen the impact of

a disaster; in this level the response plan is designed (the third level), staff are educated and

trained and necessary procedures are under taken to maximise readiness. The third level which

is actually a subset of the preparedness plan is the response plan; it outlines the procedures to

be performed if and when a disaster strikes, it will determine the chain of command, courses of

ac�on and will ul�mately determine the safety of lives. The response plan should be the first

step in every hospital disaster planning and while preparedness and mi�ga�on planning affect

the risk of disaster in near or far future, the response plan has immediate impact on risk. This

being said, however, the importance of the two other levels should not be underes�mated

because they will determine the long term risk of the hospital. In figure 3 we have provided an

outline of the hospital disaster plan.



Figure 3: Hospital Disaster Plan

The hospital faces two main categories of disasters: the internal disasters in which the hospital

is directly threatened and the external disasters in which the community that the hospital

serves is threatened and the hospital is faced with an influx of pa�ents and casual�es. The

hospital needs to have plans for both categories which are also compa�ble and can be ini�ated

simultaneously (because of situa�on where the hospital is facing both an internal and an

external threat). In our project we have provided a framework for these two categories, we

have also provided generic guidelines for responding to the common hazards faced by hospitals

in Iran. The hospitals should adopt these guidelines based on their reality while adhering to the

overall framework developed, this will ensure uniformity which helps seBng and measuring

standards by oversight organiza�ons and on the other hand will be flexible enough for hospital

administrators to design their plan based on their own condi�ons.

In figure 4 we have shown an outline of the framework designed in this project. We have

explained the elements of this framework in our previous reports.



Figure 4: Generic framework for Hospital Disaster Response Planning

Integration into NHPP:

In our view the na�onal health preparedness plan should address disaster in a three �ered

system; the first �er is the field level and will include elements such as search and rescue, field

care, field triage and transport in the acute phase, and health maintenance and oversight



ac�vi�es in the recovery phase. The second �er is where defini�ve care is provided and

consequently hospitals form the core of this �er, the hospitals are organized per their proximity

to the disaster zone; the most important are the hospitals in the immediate surroundings of the

disaster area followed by regional medical centers and finally na�onal referral centers.

Hospitals response to internal disasters if it is not in the context of a larger external disaster is

not considered a high impact event at the na�onal level, yet it is very important at the local

level making it the first �er of response. Thus hospitals not only form the core of the second �er

for disasters affec�ng the community, they are themselves the first �er and the field of disaster

when it comes to internal disasters.

We propose that this duality of threats faced by hospitals (internal vs. external) be addressed in

NHPP as well; disaster regula�ons should ensure that hospitals around the country can perform

their second �er tasks while safety regula�ons should govern the internal disasters of the

hospitals. In other words we propose that hospitals should have an internal disaster response

plan as part of their safety standards (which would apply to all hospitals) and on the other

hands selected hospitals for the second �er should have plans for external disasters (while it is

desirable for all of the hospitals to have one).

We propose that the framework developed in this project be used as a basis for planning at

both the health ministry and hospitals level. i.e. the health ministry set out the legisla�on

requiring hospitals to adhere to the framework (or a modified version of it), provide guidelines,

training and support as well as measuring and evalua�ng. This is best achieved in our opinion if

the framework is developed into a standard which hospitals are required to achieve with

transparent measurement tools as well as predetermined fines and puni�ve ac�ons. On the

other hand we believe that framework should be broad and general, leaving specific decision to

hospital administrators. This would mean that the framework should be enforced, while the

generic procedures and SOPs developed in this project or similar projects should only be

provided as guidelines. This will ensure be<er adop�on and compliance at the ground level.



TheRoadAhead:

1. The issue of risk management at hospital level in Iran needs immediate ac�on, while

some policies exist they have not been translated into ac�on at the ground level. This

needs to be addressed.

2. The first challenge is to develop the NHPP into a set of policies, regula�ons and

legisla�ons. Broad policies should be set and the posi�on of hospital disaster planning

should be defined in the system.

3. Over the years there have been many parallel and duplicate endeavours for hospital

disaster management and planning. These works need to refocused based on a common

na�onal framework; this framework should include all the elements of hospital disaster

management, this organiza�on will be<er allow us to see the weaknesses and strengths

and especially point out the parts of the framework where more work is needed for

policy development and design.

4. The na�onal framework should then be used to design general policies and legisla�ons

regula�ng the hospital disaster management, especially the standards as we men�oned

in the previous part should designed (as well as designing evalua�ng mechanisms).

5. The standards and generic guidelines that help in implemen�ng them should enforced

country wide. A feasible �meline should be agreed upon during which the

implementa�on process should reach an acceptable level.

6. An educa�on and training program is vital in ensuring the successful implementa�on of

the standards.

7. An oversight mechanism should be established to ensure the adherence to the

standards as well regular revision in the standards.

8. Documenta�on procedures should be improved, during the course of our project we

found that access to relevant informa�on is much impaired by this. A systema�c

approach to documenta�on and repor�ng as necessary as part of the NHPP. This will

help with preven�ng duplica�on, confusion and organiza�onal chaos as well allowing

for regular upda�ng and revising.

9. We propose the forma�on of technical advisory networks. We found that many experts

of the field are working in isola�on and for most part their work has no impact on real

policy making. An advisory network not only connects these experts but allows the

decision makers to u�lize their exper�se.

Documents

Emergency Hospital Service Delivery - JPRM 2011 - Final Report - English