Based on the current findings, hospital A is in a moderate safety situation (B) with a safety score of 0.57. In general, the safety status of structural, non-structural, and functional components is 0.61, 0.48, and 0.60, respectively, which shows the necessity of paying special attention to non-structural components. Hospital B's condition is completely different. With an overall score of 0.71, this hospital is placed in a safe (A) situation. In hospital B, structural components with a score of 0.82 are in the safe grade (a), non-structural components with a score of 0.60 and functional components with a score of 0.63 are in the moderate safety grade (b). Accordingly, it is necessary to pay more attention to non-structural and functional components to achieve maximum safety in this hospital. Hospital C with a safety score of 0.50 is placed in the moderate safety category (B). In hospital C, structural components with a score of 0.34 are in the unsafe grade (a), non-structural components with a score of 0.52 are in the moderate safety grade (b), and functional components with a score of 0.88 are in the safe grade (a). Because of the age of the structure and its low safety score, immediate attention to the structure and its retrofitting is a priority over other components in hospital C. Hospital D is placed in the unsafe category (C) with a safety score of 0.33 and has the most unsafe conditions among the studied hospitals. Structural components with a score of 0.24 and non-structural components with a score of 0.34 are placed in the unsafe grade (c), and functional components with a score of 0.55 are placed in the average safety grade (b). Because of the very low safety score of this hospital, immediate attention to both the structural and non-structural components is crucial.
Tabatabaei et al. measured the safety index in three hospitals in Isfahan. According to their findings, all three hospitals were in moderate safety status (B). Based on the geological risks in the area, these hospitals may be damaged and unable to operate due to an earthquake[19]. Ardalan et al. measured the safety status of hospitals in Iran once in 2012 and then again in 2015. Based on their findings, the average score of all safety components was 43.0 out of 100 (± 11.0); 82 hospitals (19.4%) were classified as non-safe, and 339 hospitals (80.6%) were classified as medium safety. No hospital was placed in the high-safety category. The average safety scores for functional, non-structural, and structural components were 41.0, 47.0, and 42.0, respectively. The average safety score increased from 34.0 to 43.0 between 2012 and 2015. According to the research findings, the safety of hospitals in Iran increased from an unsafe condition to an average safety condition in four years. In structural components, the biggest problems are the old age of the buildings and the damage and wear of the foundation and columns. In non-structural components, the main problems are related to the medical gas, water storage, communications, and electrical systems of hospitals. In functional components, crisis management and planning items have the most negative effect[16]. Djalali et al. compared the non-structural safety situations of hospitals in Tehran and Stockholm. Their findings showed that all four hospitals in Stockholm were classified as safe, while two hospitals in Tehran were unsafe and three were safe. The average non-structural safety index for Stockholm hospitals was 90% ± 2.4 and for Tehran hospitals was 64%. The main problems in Iran's hospitals are related to electrical, water storage and supply, and medical gas systems[20]. Lapčević et al. assessed the level of safety of primary healthcare centers in Serbia against flood and weather hazards. Their findings showed that health service centers have an overall safety level of 82%, and structural, non-structural, and functional components have levels of 95%, 74%, and 75%, respectively, which indicates their possible resistance to weather disasters. A detailed analysis of the impact of flood on healthcare centers showed that urgent measures are necessary to provide emergency electricity and water supplies, telecommunications, and medical equipment. In addition, this study emphasized that the risks of the study area should be taken into account in the safety assessment. In areas where weather disasters are a priority, the weight of the measured components is equal, and because of the lower impact of these disasters on the structure, it is necessary to pay attention to the non-structural and functional components[21]. Rodríguez et al. measured the vulnerability of Mexico City medical centers in structural, non-structural, and functional components against seismic damage. According to their findings, only one hospital is in good condition in structural components, and the rest of them are in poor condition. Moreover, all hospitals are in very bad condition in non-structural, functional, and administrative organization components. The main reasons for vulnerability in this study are (1) a lack of technology in the construction of earthquake-resistant buildings; (2) the need to develop or update disaster response plans; (3) the need for periodic and proper maintenance of hospital buildings; and (4) the lack of sufficient financial resources for vulnerability reduction projects[22].
As seen, the study findings are divided mainly into two parts. The results of the studies conducted in Iran are consistent with the results of the present study because of the most similar conditions; the results of hospital safety assessments in other countries are different and depend on the types of risk and the level of development. The findings of safety assessment studies from developing countries are similar to those of the present study, but the results from developed countries are different. Iran is located in the Alpine-Himalayan earthquake belt and thus has many faults and seismic zones; many areas of the country are at risk of earthquakes and other geological hazards. The earthquake risk, however, is not a priority in all regions of the country. Therefore, it is more logical to compare the results of this study with regions that have higher geological risks, because according to the WHO guide in hospital safety index calculator, the same weight cannot be assigned to all types of disaster. Therefore, some structural, non-structural, and functional components will be discussed further.
According to the WHO safety assessment guide, when geological hazards prevail in an area, structure has a greater importance than other components and gets the most weight in calculations[18]. Geological hazards, especially earthquakes, can lead to the collapse of a structure. When a structure collapses, non-structural components are simultaneously destroyed, and people who were at the scene of the accident may be injured or killed. Therefore, the whole complex will not be able to provide services and will need to receive help. For example, in the 2003 Bam earthquake, the city’s public hospitals were destroyed and unable to provide services[23]. According to the findings of this study, in structural components, one hospital is in a safe condition, one hospital is in average condition, and two hospitals are unsafe. Insecure hospitals are very vulnerable due to their age and high depreciation, and because of geological hazards prone to the area, they require immediate attention.
In non-structural components, three hospitals are in average safety condition and one hospital is in an unsafe condition. Non-structural components are very important, because even if the structure is not damaged or destroyed, services to patients and affected people may be disrupted. Ardalan et al. showed that in the 2004 Zarand earthquake, high damage to non-structural components caused the hospital to be unavailable for 6–8 hours, even though the structural components were not damaged. Non-structural components are not limited to panels, windows, and glass; among the most important of these components are electrical, communication, water supply and storage, fuel supply, fire extinguishing, medical gas, and air conditioning systems. There are other important items in this component, which we refrain from mentioning due to the length of the discussion[24]. Parise et al. stated that most hospital electrical systems are vulnerable, and damage to these systems can lead to huge human and financial losses for the hospital. In addition, the lives of critical patients may depend on support devices such as ventilators, and even a few minutes of a power outage may endanger their lives. Moreover, fluctuating electricity may cause damage to capital and expensive devices[25]. Cid et al. reported that during disasters, communication is likely to be disrupted, possibly because of direct damage to the communications system, such as the destruction of masts, or because the system is unable to respond due to an increase in the consumption load[26]. Therefore, it is necessary to pay attention to the safety of communication systems and to use alternative systems. In the present study, hospitals were observed to rely more on the current communication system (telephone), using the satellite phone for alternative communication. Considering the dangers of the region, the possibility of telecommunication masts falling in an earthquake, and telephone lines possibly being disconnected, it is better to predict the increase of methods of communication and buy them for practice and use. Matsumura et al. reported that after the Great East Japan Earthquake, water reserves were greatly reduced, and hospitals were unable to provide services at times. The reduction of water reserves in Japan occurred for two reasons: first, direct damage to water storage tanks, cracking and breaking of connections, and wasting a large amount of stored water, and second, an increase in the number of earthquake victims which led to an increase in the number of hospital visitors, As a result, the system was not able to provide the required amount of water[27]. In their study, Shastri et al. emphasized that hospitals are always at risk of fire due to the presence of medical gases, flammable liquids, and other flammable materials such as fabrics and papers as well as the excessive use of electric current. As many people in the hospital are mostly unable to take care of themselves, the occurrence of such incidents can have disastrous results. The researchers also emphasized that to ensure fire extinguishing, it is better to use several complementary methods such as air evacuation, sprinklers, and fire capsules as well as smoke and fire detectors[28]. Paul et al. stated that medical gases are one of the most essential components of the hospital, and their flow should never be interrupted under any circumstances, because the lives of many patients depend on breathing oxygen. Nonetheless, medical gases can lead to explosions and fires because of their high flammability and being under pressure in capsules. Moreover, they can endanger the lives of many patients because of the interruption of oxygen flow. The researchers showed that most of the studied hospitals have average and unsafe safety conditions in medical gas safety[29]. In their study, Guo et al. pointed out the importance of air conditioning systems during the outbreak of the Covid-19 pandemic. They showed that the proper functioning of the air condition and air circulation system can significantly reduce the risk of virus contraction among staff and patients. They suggest that all air conditioning systems should be reviewed, and filters such as HEPPA should preferably be used for air purification. In addition, the filters should be changed immediately at the appointed time according to the instructions of the filter manufacturer[30].
In functional safety, most of the hospitals in this study were in medium and high safety conditions, and only one hospital was in an unsafe condition. Functional components in geological hazards have the lowest weight among other components. It should be noted, however, that low weight does not indicate unimportance. Functional components are the hospital's plan for how to operate in different stages of crisis management, and no organization can achieve its goals without a plan. Various plans and special attention to training and re-training are the most important elements of functional components, which require the participation of hospital managers and officials as well as other personnel. Programs will not be successful without the participation of the stakeholders and the people who are going to implement them. Therefore, to achieve the maximum safety score in functional components, it is necessary to involve all people in formulating programs and practicing them, because in addition to increasing the understanding of the contents of the programs, a guarantee for their implementation is also provided. Finally, it should be noted that according to the weak chain theory, the structural, non-structural, and functional components of a hospital are like the links of a chain: a weakness in any of them may cause the whole complex to break. The findings of other studies in Iran and developing countries show that most hospitals in these countries have similar problems in facing disasters. Therefore, it is possible to use the experiences of other countries in the field of safety and to carry out retrofitting programs before disasters occur.
Paying attention only to the safety score is not enough to achieve the goal of a safe hospital. Risk analysis studies indicate that at a certain risk level, hospitals with a higher vulnerability score are more likely to be seriously damaged by disasters. This issue is evident in hospital D in the present study. For example, at the vulnerability level of 67% total and 76% in structural components, it is quite clear that a strong earthquake could destroy this hospital. In their study, Karapetrou et al. emphasized that the level of vulnerability of critical infrastructures in a community, such as a hospital, can indicate the possibility of the community being affected during a major disaster. Therefore, in addition to the safety percentage, special attention should be paid to the vulnerability score of the components when developing retrofitting plans for critical infrastructures[31]. As seen, a hospital may be vulnerable in only one important component, and the overall safety score does not reflect its condition well. In this situation, paying attention to the vulnerability score can solve the problem and make the retrofitting program more practical. In addition, in recent years Building Information Modelling (BIM) has been found as a solution for disaster planning and management. BIM can be utilized to facilitate information storage and exchange among the various participants in case of disasters. For instance, in a recent study conducted by TohidiFar et al., a hybrid BIM and Bayesian Networks (BN) was developed to enable the hospital team members to understand the utility systems and respond more quickly to critical incidents[32].