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Abstract
Objective Despite ‘hospital resilience’ gaining prominence in recent years, it remains poorly defined. This article aims to define hospital resilience, build a preliminary conceptual framework and highlight possible approaches to measurement.
Methods Searches were conducted of the commonly used health databases to identify relevant literature and reports. Search terms included ‘resilience and framework or model’ or ‘evaluation or assess or measure and hospital and disaster or emergency or mass casualty and resilience or capacity or preparedness or response or safety’. Articles were retrieved that focussed on disaster resilience frameworks and the evaluation of various hospital capacities.
Result A total of 1480 potentially eligible publications were retrieved initially but the final analysis was conducted on 47 articles, which appeared to contribute to the study objectives. Four disaster resilience frameworks and 11 evaluation instruments of hospital disaster capacity were included.
Discussion and conclusion Hospital resilience is a comprehensive concept derived from existing disaster resilience frameworks. It has four key domains: hospital safety; disaster preparedness and resources; continuity of essential medical services; recovery and adaptation. These domains were categorised according to four criteria, namely, robustness, redundancy, resourcefulness and rapidity. A conceptual understanding of hospital resilience is essential for an intellectual basis for an integrated approach to system development. This article (1) defines hospital resilience; (2) constructs conceptual framework (including key domains); (3) proposes comprehensive measures for possible inclusion in an evaluation instrument; and (4) develops a matrix of critical issues to enhance hospital resilience to cope with future disasters.
- emergency care systems
- management, risk management
- mass incidents
- assessment
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Introduction
In recent times, the concept of disaster resilience has gained importance in the light of the increased frequency and impact of disasters, including natural disasters, pandemics and terrorism.1 The notion of resilience can encompass the qualities that enable the individual, organisation or community to resist, respond to and recover from the impact of disasters.2 Healthcare resilience, especially hospital resilience, is essential as it provides ‘lifeline’ services for minimising the impact of disasters on the community and achieving higher community resilience.1 ,3–5
There are still a few studies that have focused on hospital resilience. Instead, considerable work has been undertaken aimed at defining hospital capacity to cope with disasters from different perspectives using various concepts, such as hospital safety, hospital preparedness, hospital business continuity and surge capacity. Additionally, international organisations such as WHO and PAHO, and countries such as the USA, have developed specific tools and specific measures mainly to evaluate hospital disaster preparedness and hospital safety.4 ,6–15 However, these disaster concepts occur in isolation, provide limited perspectives of disaster capacity and result in gaps, and, at times, duplication.16 For instance, there was a great deal of overlap but little consistency in what constitutes ‘hospital preparedness’ or how it should be measured. Most hospital preparedness studies have focussed on a full range of management activities, not just those designed to enable responses to events. The preparedness documents reviewed rely nearly exclusively on structural measures (eg, human, equipment), but have little concern for hospital infrastructural safety and emergency services, which are linked to the hospital's ability to cope with disasters.16 ,17 There is little consensus regarding which measures should be selected and how to integrate these measures into a comprehensive framework for measuring core hospital capacity. Thus, developing the concept of ‘hospital resilience’ would provide a starting point for broad agreement about what comprises hospital core capacity and assist in integrating this capacity into a comprehensive whole view.
Given the critical role of hospitals, the model of ‘safe and resilient hospitals’ was promoted as a key component of disaster risk reduction planning in the healthcare sector during the 2005 World Conference on Disaster Reduction.18 ,19 This conference endorsed policies that ensure ‘that all new hospitals are built with a level of resilience that strengthens their capacity to remain functional in disaster situations’.18 ,19 To improve hospital resilience for disasters, it is essential to clearly define the concept and to identify its key domains.
There is some imperative for devising a user-friendly assessment instrument for hospital resilience that can maximise the concept development. Such an instrument could be used to better understand the full extent of hospital resilience and also as a decision-support tool for promoting strategies and policies aimed at improving hospital resilience. To date, there are few studies that have identified the key domains of hospital resilience, let alone developed an assessment instrument.
This article aims to build a conceptual framework from the literature, which identifies the key domains of hospital resilience so as to highlight issues that could be used for measurement and improvement. The study has four objectives (1) it defines hospital resilience; (2) it constructs a conceptual framework (including key domains); (3) it proposes measures for possible inclusion in an evaluation instrument; and (4) it develops a matrix of critical issues to enhance hospital resilience to cope with future disasters.
Methods
Major health electronic databases including ProQuest, EBSCO, Web of Science, PubMed and ScienceDirect were searched to retrieve relevant publications, including reports, grey literature and published articles that may be applicable to research aims and objectives. Two sets of search terms were used, namely, (1) ‘resilience and framework or model’ or (2) ‘evaluation or assess or measure and hospital and disaster or emergency or mass casualty and resilience or capacity or preparedness or response or safety’. Additional references were identified through examination of the references from most recent publications (snowballing) and through scrutinising the contents pages of highly relevant journals from the last 2 years.
Inclusion criteria were: (1) journal articles, reports and grey literature written in English; (2) within the first search strategy, studies that include disaster resilience frameworks, models or key domains; and (3) within the second search strategy, studies that identify instruments and associated measures for assessing aspects of hospital disaster capacity.
Exclusion criteria were: (1) within the first search strategy, studies that only focused on individual resilience, staff resilience and resilience engineering without relevance to hospital resilience; and (2) within the second search strategy, studies without any evaluation instruments that could assist to inform the identification of measures to evaluate hospital disaster capacity.
The titles and abstracts of articles were reviewed by the principal researcher (SZ) for relevance and significance and the full text of articles retrieved when appropriate. Full-text articles were analysed for their contribution to the definition, conceptual understanding of resilience, identification of the domains of hospital resilience and possible evaluation measures. Publications, including public reports, grey literature and journal articles written in English were included in this review, spanning the years 1981 to Feb 2013. A widely accepted measurement definition has been used in this study.17 ,20 The term ‘measure’ includes a statement about the existence or performance of healthcare that is deemed to contribute to hospital resilience under relevant domains and subdomains. An instrument is a collection of these measures.
This article covers all four objectives around a logical core. First, evidence that contributed to the concept and definition of hospital disaster resilience was identified. Second, existing frameworks from other sectors and their underpinning domains were identified and evaluated for their applicability to the health sector. From this analysis, a draft conceptual framework was developed for further testing and evaluation. Finally, evidence of resilience measures was sought along with instruments of hospital capacity in the context of disasters (eg, hospital safety, hospital disaster management).
Two reviewers assessed the suitability of these measures based on each measure's relevance to the hospital resilience concept, which includes hospital structural components, non-structural components, emergency medical functions and disaster management. In cases of substantial disagreement between the reviewers, the potential measures were still included in the framework for further experts’ discussion. Such an approach aims to minimise the chances of missing or rejecting a relevant measure. Measures need to be included in at least one instrument, with perceived relevance to the definition of hospital resilience or its measurement. The purpose of this extraction was to allow documentation of measurement domains for hospital disaster resilience, which is a foundation for future evaluation.
Result
A total of 1480 potentially eligible publications were retrieved initially. Of these 1193 were excluded through screening the title and then the abstract. After scanning the full text of the remaining 287 publications, the final analysis was conducted on 47 articles, which appeared to contribute to the study objectives.
As hospital resilience is a relatively new concept and focus of attention, there is still no agreed conceptual framework for its usage. There are existing disaster resilience frameworks of non-hospital sectors, such as communities or organisations. We reviewed these frameworks as a basis for a better understanding of the disaster resilience domains. However, we have not included frameworks that do not appear to have significance for the health sector in this document. For instance, many publications were not included that devised frameworks or models using sophisticated mathematical modelling and calculations, which came largely from a resilience engineering paradigm.
Four relevant disaster resilience frameworks, which focus on community disaster resilience and organisation resilience, were selected.1 ,21–23 The selected frameworks were user-friendly and interpretable at the lay level with a description of key domains or criteria for disaster resilience that can be adapted into the hospital resilience context. The disaster resilience frameworks are described in the discussion section.
Evidence of resilience measures was sought along with instruments for measuring hospital capacity in the context of disasters (eg, hospital safety, hospital disaster preparedness). Research sourced for the second search strategy was expected to be used to synthesise potential measures that could be used for evaluating hospital resilience and for highlighting critical issues to enhance hospital resilience. A total of 11 studies were located, which focussed on instruments that evaluated hospital disaster capacity (eight peer reviewed articles and three public reports). Each of the 11 studies contains an instrument with associated measures for assessing aspects of hospital capacity in responding to disasters.4 ,6–15 Table 1 displays the data and categories extracted from each instrument.24 ,25 Most studies (n=7) focused on hospital preparedness for disasters, and on hospitals’ response and recovery capability and surge capacity. Other studies evaluated hospital safety to disasters (n=2) or else focused on hospital linkages with the community during disasters (n=2). It is noteworthy that a large number of the studies were based on US experiences post 9/11. Common limitations of these studies included a focus on specific disasters rather than all hazards, lack of reliability and validity, lack of scoring procedures or self-report without further verification.
There are also several challenges derived from measures of these instruments. First, one of the characteristics of good measures is that they encode clear standards with the data elements explicitly detailed.26 Many of the measures in the evaluation instruments were subjective in the form of checklists or questionnaires. For example, measures of timely reporting of key diseases often failed to specify thresholds for timeliness and completeness or whether those thresholds varied by the reportable conditions. These issues of clarity preclude a description of the validity of identified measures, which was also lacking in the identified instruments. Second, ideal measurement systems span the Donabedian categories of structure (capacity), process (service) and outcomes.27 ,28 Structure measures are the human, physical and financial resources available to provide healthcare. Process measures describe the care or emergency health service provided to the patient. Outcome measures are the resulting effect on the health of the patient or population.27 ,28 However, the preparedness documents reviewed rely nearly exclusively on structural measures (eg, human resources, plans, equipment) over process (emergency service) and outcome.
Discussion
Defining hospital resilience
Hospital resilience is a comprehensive concept that includes structural components (eg, facility safety), non-structural components (eg, staff, medication and equipment), emergency medical functions (eg, continuity of medical service) and disaster management capacity (eg, plan and procedure, crisis communication, community linkage).29 In order to be resilient, hospitals need to withstand the event, with both inherent strength (ability to resist and respond to an external shock) and adaptive flexibility (ability to bounce back and adapt). At the same time they are expected to be able to provide emergency medical services and surge their capacity to respond to sudden increases in demand associated with disasters.30–32
Hospital disaster resilience can be comprehensively defined as ‘hospital's capability to resist, absorb, respond to the shock of disasters while still retaining their most essential functionality (eg, prehospital care, emergency medical treatment, critical care, decontamination and isolation), then recover to its original state or a new adaptive state.’1–3 ,33 ,34 More specifically, ‘hospital resilience is the capability to absorb the impact of disasters without loss of functions (termed resistance); maintain its most essential functions (called absorption and responsiveness); and ‘bounce back’ to the pre-event state (termed recovery) or to a new state of function (termed adaptation).’ These capacities are achieved through a wide variety of measures and strategies.35
Development of hospital resilience conceptual framework
In the absence of any existing framework, domains drawn from other sectors, such as community or organisation resilience may have applicability to health services and may help inform a hospital resilience framework. These frameworks are discussed below and used for development of a conceptual framework for hospital resilience.
An Australian government disaster resilience model was developed by undertaking a thematic analysis of the community resilience literature. Its four domains are community connectedness; risk and vulnerability; planning and procedures; and available resources. These domains overlap and interact, making relatively equal contributions to building community resilience.21 Healthcare resiliency sits at the centre of several integrated domains, including emergency management, risk management, safety/security, business continuity, disaster recovery and crisis communications.22 One organisational resilience report concluded that the concept of ‘adaptive capacity’ is an essential part of resilience.23 Adaptive capacity is defined as the ability of an organisation to alter its strategy, operations, management systems, leadership structure and decision-support capacity to withstand disasters, generally by adopting adaptive qualities and proactive responses.23
Arguably one of the most used resilience frameworks is the MCEER's framework. It has been used recently to describe community and organisational resilience in the context of seismic risks.1 ,33 ,36–38 The framework includes four criteria, two of which, robustness and rapidity are seen as ‘ends’, and two of which, resourcefulness and redundancy, are seen as ‘means’. The model integrates these criteria into four domains of community resilience.1 All of these criteria can be used to examine disaster resilience for various types of physical and organisational systems,1 ,33 ,36 ,39 such as healthcare systems and hospitals.33 ,36 ,40
Figure 1 can be used to better understand the relevance of these resilience criteria to hospital disaster resilience. The extent of a hospital's resilience can be measured with reference to the level of hospital function, such as the number or percentage of patients assessed and treated. The horizontal line showing full hospital operation is fixed, implying a single optimum. The occurrence of a disaster leads to a rapid decrease in function performance. The extent to which the function is maintained reflects the hospital's robustness. Over time, the hospital regains some level of equilibrium. The speed with which this recovery of function is achieved reflects the hospital's responsiveness (rapidity). Robustness and rapidity can be improved by both preparedness and responsiveness activities.36
Understanding hospital disaster resilience criteria (adapted by the authors, from Bruneau et al 2003).
It would appear timely to establish a new conceptual framework by adapting relevant resilience frameworks to a hospital resilience context. Existing resilience frameworks are not hospital-focused. This may limit the extent to which existing frameworks can be directly applied to complex entities such as hospitals, although, it is anticipated that there may be some domains of these frameworks that may have relevance to a hospital setting.
We have adapted the disaster resilience domains for hospital resilience. The initial key domains were aggregated to incorporate all the hospital's key capacities to cope with disasters, including hospital safety (surveillance, safety/security), hospital disaster preparedness and resources (disaster planning and procedure, crisis communications, community connectedness, available resources and logistics management), continuity of essential medical services (emergency medicine, medical continuity and surge capacity), recovery and adaptation (recovery, evaluation and adaptation).21 ,22
The MCEER's framework includes four criteria of disaster resilience, including robustness, resourcefulness, redundancy and rapidity. These criteria can be integrated into the four domains of hospital resilience via a conceptual framework illustrated as figure 2.
Conceptual framework of hospital and healthcare resilience (developed by the authors).
It has been developed to provide a holistic interpretation of our understanding of hospital resilience. Within this conceptual framework, hospital resilience can be assessed by robustness, redundancy, resourcefulness and rapidity, which is in-turn, influenced by a complex of various adapted resilience domains. This new framework links key domains and hospital management approaches with an achievable goal of improving hospital pre-event robustness and promoting rapid response and recovery.41–44 It is hoped that the ethos of hospital resilience may be consistent with, and contribute to, integration of the core capacity into a comprehensive hospital disaster management framework.22 It is essential to put hospital disaster capacity, management activities and disaster outcomes together into a comprehensive whole view using an integrated approach.
Developing the conceptual framework of ‘hospital resilience’ would provide a starting point for broad agreement about what comprises hospital core capacity in the context of disasters, and would also assist in integrating this broad range of capacities together into a comprehensive whole view. By adapting the key domains into the hospital context, it is hoped that this new conceptual framework for health will be consistent with an all agencies approach, and an approach that promotes the integration of hospitals within the community.
Measuring hospital resilience
The preliminary conceptual framework of hospital resilience can be used as a foundation to further develop an instrument with potential measures for evaluation. While recently some work (eg, preparedness, response capability, surge capacity) has been done on hospital capacity to cope with disasters, these current studies have added to the body of knowledge as it is the first time that a conceptual framework has been developed for disaster resilience and that the work will enable hospitals to examine their level of resilience. This is the first time that the literature has been examined from a holistic perspective in order to draw the diverse measures into a coherent whole.
The search extended to hospital disaster studies (eg, hospital safety, hospital disaster preparedness, response capability, surge capacity) and sought to describe the possible domains of the framework, and provide measures for further evaluating hospital resilience. All selected studies illustrated in table 1 focus on the evaluation of hospital capacity to cope with disasters. Although the foci of these studies were different and not all their component parts are directly comparable, a number of domains were identified. Within each domain, we classified subdomains. For example, within hospital safety, we identified disease surveillance, hospital safety and vulnerability as subdomains.
The purpose of this classification was to allow documentation of measurement domains and comparisons of the scope of the instruments. The authors discussed the relevant subdomains and achieved agreement on the extracted main subdomains, namely, hospital internal safety, disease surveillance, emergency leadership, disaster plan, community linkage, crisis communications, emergency staff, available resources and logistics management, disaster trainings and drills, emergency response, medical treatment, surge capacity and hospital disaster recovery and adaptation. The priori hypothesis has been approved that the extracted key domains or particular subdomains be consistent with preliminary recognised domains of hospital resilience. All domains and subdomains were addressed by at least one evaluation instrument. The measures were also extracted and synthesised within these subdomains. These measures are relevant to the concept of hospital resilience and at least one of basic resilience criteria including robustness, resourcefulness, redundancy and rapidity.1 ,33–38 Similar measures across papers were merged in order to ensure key measures, which captures similar meanings from different papers.45 ,46
Through extracting and synthesising measures, a comprehensive framework was constructed for documentation of the measurement domains of hospital resilience, which integrate potential measures for future development of an evaluation instrument. There are four primary domains, 12 subdomains and 46 potential measures illustrated in table 2.
The domains and subdomains included hospital safety and vulnerability (surveillance, hospital internal safety); hospital disaster preparedness and resources (emergency leadership, community cooperation and crisis communication, disaster plans, disaster stockpiles and logistics management, emergency staff, emergency trainings and drills); continuity of essential medical service (emergency response, emergency medicine, emergency surge capacity);and recovery and adaptation (recovery, evaluation and adaptation). Recognition of an evaluation framework provides a foundation for a more comprehensive instrument for measuring a hospital's resilience. This instrument could be converted to a self-assessment questionnaire, using dichotomous indicators, multisection indicators or quantitative indicators. Alternatively, it could be developed as a scorecard or checklist.
Critical issues for enhancing hospital resilience
Table 3 is a comprehensive matrix of hospital resilience with potential measures adapted from the conceptual framework. All measures are categorised to various domains of the conceptual framework for a higher level of interpretation and better understanding of the concept.
Proposed metric of hospital resilience: critical issues for enhancing hospital disaster resilience
Robustness describes a hospital's inherent strength to withstand the consequences of an event. Redundancy is achieved through backup and surge capacity of staff, infrastructure, resources and equipment. Resourcefulness is an adaptive flexibility for maintaining hospital essential services. Rapidity reflects the speed of hospital responsiveness through fixing things up, bouncing back, functional recovery and adaptation. All the identified hospital resilience measures are included in one of the four basic resilience criteria.1 This matrix can be used to guide the operationalisation of the concept of hospital resilience, and for identifying critical issues for enhancing hospital resilience in disasters. It is noted that table 3 is only used for illustration, and needs to be further developed.
Strengths and weaknesses
This is the first step in a comprehensive body of work designed to develop a conceptual framework for understanding hospital resilience and its domains, and to identify possible measures. This first step is to draft a working draft model with a view to seeking expert commentary. This will be done as part of the research project, but we also believe that this will be enriched by broader professional commentary beyond that of the research as would result from discussion of the draft. We have attempted to adapt conceptual frameworks from other sectors as a basis for a better understanding of the disaster resilience domains. However, we have not included frameworks that do not appear to have significance for the health sector in this document. This adapted framework is expected to be consistent with an ‘all agencies’ approach, which promotes integration of hospitals within the community. But the new framework does need to adapt ‘non-health’ frameworks as direct translation is likely to be inappropriate, and there is little validation of those frameworks even in the principal areas of their focus.
Measures were also identified on the grounds that these describe the domains of the framework and provide a means of further evaluating hospital resilience. The candidate measures may form a suitable measurement tool for evaluating hospital resilience, and for measuring the impact of improvement strategies. However, before they can be used for empirical studies, reliable measures need to be selected, modified or validated further. The additional consideration by experts is needed for its development to a user-friendly instrument. The measures in the framework were still in the form of checklists without clear evaluation standards or benchmarks. This is because the extant evidence base is insufficient to determine either the capacity or the process measures that are linked to desirable outcomes or the levels of those measures that would be regarded as adequate.17 In the future, empirical outcomes from hospital surveys are also needed for further testing the feasibility and validity of these measures, and further developing it into a measurement instrument (eg, self-report questionnaire) for evaluating hospitals in pilot areas. Then explicitly details regarding the average or desired level of capacity or performance of the hospitals in the pilot areas can be produced.
Conclusion
A conceptual understanding of hospital resilience is essential to provide an intellectual basis for an integrated approach to system development. To date there is no agreed framework for hospital resilience that would form the basis of measurement of resilience. This article (1) defines hospital resilience; (2) constructs a conceptual framework (including key domains); (3) proposes comprehensive measures for possible inclusion in an evaluation instrument; and (4) develops a matrix of critical issues to enhance hospital resilience to cope with future disasters.
Developing the concept of ‘hospital resilience’ will provide a starting point for agreement about what it comprises and how to measure it. The new concept links these key components with an achievable goal to improve hospital pre-event robustness as well as rapidity to recover and adapt for disasters. The development of a conceptual framework with underpinning measures will be useful for furthering the understanding and discussion around hospital resilience. Expert advice will add further to the development of the framework. Future research will develop and validate an instrument that will allow hospitals to measure their level of resilience and thus aid in building their capacity.
Acknowledgments
Thanks to the QUT–CSC joint scholarship and the contributions of all the co-authors. This study forms part of the principal author's PhD research, which focuses on the definition and evaluation of hospital disaster resilience. Further qualitative research and primary empirical data collection will seek to test the feasibility and utility of this conceptual framework and of the measures identified in this article.
References
Footnotes
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Contributors SZ jointly designed the study, reviewed, read and analysed the relevant literature and jointly wrote the manuscript. GF, MC, YLZ and XYH jointly designed the study and jointly wrote the manuscript.
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.