Hospital Safety Index

Guide
for Evaluators

Hospitals Safe from Disasters

 Series Hospitals Safe from Disasters, N° 1

Hospital Safety Index

Guide for Evaluators

S A LU
O T
PR

O P
A
P H
S O
N

O
VI MU ND
I

Washington DC, 2008

© Pan American Health Organization
 PAHO HQ Library Cataloguing-in-Publication
Pan American Health Organization
Hospital Safety Index: Guide for Evaluators
Washington, D.C.: PAHO, © 2008
107 p.-- (Series Hospitals Safe from Disasters, 1)
ISBN 978 92 75 13256 2

I. Title II. (Series)

1. ARCHITECTURE AND CONSTRUCTION OF HOSPITALS
2. PREVENTION AND MITIGATION
3. REGULATIONS AND CONTROL OF HEALTH FACILITIES
4. SECURITY – guidelines
5. EVALUATION OF HEALTH SERVICES
6. HOSPITALS
7. DISASTER PLANNING – planning and management
8. GUIDELINES

NLM WX 185

© Pan American Health Organization, 2008

A publication of the Area on Emergency Preparedness and Disaster Relief of the Pan American
Health Organization, Regional Office of the World Health Organization (PAHO/WHO).
The views expressed, the recommendations made, and the terms employed in this publication do
not necessarily reflect the current criteria or policies of PAHO/WHO or of its Member States.
The Pan American Health Organization welcomes requests for permission to reproduce or trans-
late, in part or in full, this publication. Applications and inquiries should be addressed to the Area on
Emergency Preparedness and Disaster Relief, Pan American Health Organization, 525 Twenty-third
Street, N.W., Washington, D.C. 20037, USA; fax (202) 775-4578; e-mail: disaster-publications@
paho.org.
This publication has been made possible through the financial support of the Division of Hu-
manitarian Assistance, Peace and Security of the Canadian International Development Agency (HAPS/
CIDA) and the Office of Foreign Disaster Assistance of the United States Agency for International
Development (OFDA/USAID).
 Contents

1. Acknowledegements ............................................................................................................ 5

2. Preface ............................................................................................................................................ 7

3. Aim, objectives and contents of this guide ............................................................ 9

4. Conceptual aspects of risk reduction .......................................................................11

5. Hospitals safe from disasters .........................................................................................13

6. Hospital Safety Index ...........................................................................................................15

7. Procedures and recommendations for evaluating

health facilities.........................................................................................................................17

8. Brief description of the evaluation forms ...............................................................23

9. How to calculate the Hospital Safety Index ..........................................................27

10. Using the Checklist ...............................................................................................................29

11. Glossary........................................................................................................................................77

12. Bibliography ..............................................................................................................................81

13. Annex 1 ........................................................................................................................................83

14. Annex 2 ........................................................................................................................................89

3
 ACKNOWLEDGEMENTS 1
T
he Hospital Safety Index represents a significant collective achievement in improving the safety
of health facilities, an area PAHO/WHO has promoted and supported for more than 20 years.
Disaster mitigation activities have been carried out with a large number of actors, both public
and private, individuals and institutions. Many countries in the Americas have achieved important
progress in terms of making their health facilities safer, more resilient and better prepared in disaster
situations. This accumulated knowledge has made it possible to develop a practical tool such as the
Hospital Safety Index, which has been compiled and tested over the last two years until consensus was
reached for its publication and distribution. Comments and observations are certain to arise as the
Index continues to be applied and these will enable us to improve future editions.
PAHO/WHO wishes to recognize all the specialists and organizations that have supported this
process, and in particular those who have taken part in a practical way in the development of the Hos-
pital Safety Index. Some of these people belong to PAHO/WHO’s team of experts from the Disaster
Mitigation Advisory Group (DiMAG). The list of authors and of those who have contributed is as
follows:

Main contributors
Carlos Llanes Burón, from Cuba
María Luisa Rivada Vázquez, from Cuba
Felipe Cruz Vega, from México
Guadalupe Gaona, from México
Luis Alfonso Cervantes, from México
Marcela Cámpoli, PAHO/WHO consultant

Other members of the DiMAG and national experts who participated in the review of the
checklist, the Safety Index Calculator and the Guide for Evaluators:
Tony Gibbs, from Barbados; David Taylor, from PAHO/WHO; Carlos Zavala and Alberto
Bisbal, from Peru; Miguel Cruz and Rocío Sáenz, from Costa Rica; Agustín Gallardo and
Ruben Boroschek, from Chile; Ferdinard Recio, from Mexico; as well as several experts from
the San Simon University, in Cochabamba, Bolivia and the School of Civil Engineers, in
Manabi, Ecuador.

Participants from PAHO/WHO’s Area on Emergency Preparedness:

General coordination of the Index’s development: Ciro Ugarte.
The following people took part in the review process: Dana Van Alphen, Carlos Roberto
Garzón, Patricia Gómez, Leonardo Hernández, Alejandro Santander, and Monica Zaccarelli
Davoli.
The editorial revision was coordinated by Ricardo Pérez.
The graphic design was carried out by Rosario Muñoz and Victor Ariscain.

5
 PREFACE 2

W
hen disaster strikes, a community’s critical services must be able to protect the lives and
well-being of the affected population, particularly in the minutes and hours immediately
following impact. The ability of health services to function without interruption in these
situations is a matter of life and death. It is imperative that all health services are housed in structures
that can resist the force of natural disasters, that equipment and furnishings are not damaged, that vital
connections (such as water, electricity, medical gases, etc.) continue to function, and that health person-
nel are able to provide medical assistance when they are most needed.
The countries of the Americas1, along with more than 160 countries around the world at the 2005
World Conference on Disaster Reduction,2 adopted “Hospitals Safe from Disasters” as a national risk
reduction policy in order to ensure that all new hospitals are built to a level of safety that will allow
them to function in disaster situations. ‘Safe hospitals’ initiatives also call for the use of mitigation mea-
sures to reinforce existing health facilities, particularly those providing primary health care.
Defining the term ‘safe hospital’ will help to guide the process. According to the PAHO Disaster
Mitigation Advisory Group (DiMAG), a safe hospital is a facility whose services remain accessible and
functioning at maximum capacity and in the same infrastructure, during and immediately following
the impact of a natural hazard. Today, thanks to their contribution and to inputs from national experts,
a rapid and low-cost diagnostic tool—the Hospital Safety Index—has been developed to assess the
probability of a hospital or health facility remaining operational in emergency situations.
This “Guide for Evaluators of Safe Hospitals” provides a step-by-step explanation of how to use
the Safe Hospitals Checklist, which leads to obtaining the hospital’s Safety Index. It also serves as the
basic reference document for those responsible for evaluating hospital safety in disaster situations.
Applying the Safe Hospitals Checklist yields useful information about a facility’s strengths and
weaknesses. Once the evaluation is complete, the evaluation team presents its findings to the hospital
board of directors and staff. The hospital staff will be responsible for making the changes needed to
improve the hospital’s safety level, within the recommended time frame.
The Hospital Safety Index provides an overview of the probability of a hospital or health facility
remaining operational in emergency situations taking into account the environment and the health
services network to which it belongs. As a comparison, it is like an out-of-focus snapshot of a hospital:
it shows enough of the basic features to allow us to quickly confirm or reject the presence of imminent
risks.
It is important to point out that the Index was built with the knowledge of professionals from
different specializations and that consensus was achieved following intense discussions and its applica-
tion in a limited number of health facilities (around 200). The Index also has an element of subjectivity
on the part of the specialists using it. Experts recognize that it is the best system of rapid evaluation
that exists, but that it is probable that it will need to be revised in the near future after its large-scale
application.

1 Resolution CD45.R8 Disaster Preparedness and Response: www.paho.org/english/gov/cd/CD45.r8-e.pdf.

2 Hyogo Framework for Action 2005-2015: Building the resilience of nations and communities to disasters. www.unisdr.org/eng/hfa/hfa.
htm.
7
 AIM, OBJECTIVES AND 3
CONTENTS OF THIS GUIDE

T
he purpose of this guide is to have an orientation document to estimate the Hospital Safety
Index, that will facilitate the determination of the hospital’s capacity to continue providing
services after a natural adverse event, and guide necessary intervention actions to increase the
hospital’s safety in case of disasters.
The objectives of this Guide are:
a. To give evaluators an objective and standardized approach to applying the Safe Hospitals
Checklist, so that they can make an initial determination about whether or not the hospital
will be able to function in the immediate aftermath of a disaster.
b. To recommend activities and measures to improve hospital safety.
c. To provide standard criteria for elements that will be evaluated in different contexts.
d. To simplify recording and classifying information about the strengths and weaknesses found
in a health facility, individually and as part of a health service network.
e. To support groups of experts from a variety of disciplines who are committed to risk reduction
and disaster response.

This Guide includes sections on methodology, two forms and a section on using the safety index and
a basic glossary of terminology.
a. The methodology section provides the evaluator with an overview of the process and what to
consider when using the checklist.
b. Form 1, “General Information About the Health Facility” (in Annex 1) is filled out by the
facility being evaluated.
c. Form 2, the “Safe Hospitals Checklist” (Annex 2) is completed by the evaluation team.
d. Guidance as to how to calculate the “Hospital Safety Index”.
e. Glosary: provides standardized vocabulary for all those involved in the process.

While this document was developed for health service facilities, it can be used as a reference to
evaluate other public services and facilities carrying out the corresponding technical adaptations and
taking into account national and international standards.

9
 CONCEPTUAL ASPECTS 4
OF RISK REDUCTION

N
early all communities are exposed to a variety of adverse phenomena, whether of natural ori-
gin or caused by human activity. Among these are hurricanes, floods, earthquakes, forest fire,
drought, volcanic eruptions, chemical accidents, terrorist attacks, and outbreaks of disease.
All of these adverse events disrupt the routine life of a community and have a range of human and
material consequences. Homes are destroyed, communities are isolated, and basic services are damaged.
People lose their jobs and businesses; crops are destroyed and agricultural production is brought to a
standstill; domestic animals are lost. There is chaos. People go missing, are injured, or killed.
Disasters are not natural. Disaster risk, defined as the likelihood that damages will overwhelm
the ability of the affected community to respond, is the function of a hazard in combination with vul-
nerability. The hazard, which is the probability that a potentially damaging phenomenon will occur,
interacts with vulnerability, which is the likelihood that a community will be adversely affected by that
hazard. Hazards can be of natural origin or caused by human activity, but vulnerability is always an
expression of planning, construction, and development. Communities have more or less resilience to
the disasters that occur at their location.
The extent and severity of the damage caused by an adverse event is inversely proportional to the
level of resilience of a community: the more resilient, the less damage. Finally, the capacity to respond
determines whether an adverse event will be an emergency or develop into a disaster.
Human activity determines the likelihood of damage and the capacity to respond to a disaster. The
main factors influencing disaster risk are: human vulnerability expressed primarily by levels of poverty
and social inequality; rapid population growth, mainly among the poor who settle in areas that present
a variety of natural hazards (e.g., river beds, riverbanks, and steep slopes); increasing environmental
degradation, particularly because of poor land-use practices and their impact on climate change; poor
planning; and the lack of early warning systems.
We can say, then, that disasters “respect” borders and social conditions. Disasters cause propor-
tionally more damage to developing countries and the poorest communities. Hurricanes can hit two
countries or two communities with the same wind speed and amount of rain, but the extent of damage
to lives, infrastructure, and health services will be very widely divergent because of different levels of
vulnerability in the two communities.

11
 HOSPITALS SAFE FROM DISASTERS 5

A
ccording to information from the Member Countries of PAHO/WHO, 67% of the Region’s
approximately 18,000 hospitals are located in areas with disaster hazards.3 In the last decade,
some 24 million people were without health services for months and sometimes for years as
a direct result of disaster damage. In the Region of the Americas, it is estimated that a hospital that is
out of service leaves some 200,000 people without health care. The loss of emergency services during
disasters severely lessens the possibility of saving lives.
According to a report prepared by the U.N. Economic Commission for Latin America and the
Caribbean (ECLAC),4 damage to health infrastructure caused by disasters in the Region of the Ameri-
cas amounted to more than US$ 3.12 billion over a 15-year period. When we factor in the health costs
for the millions who went without health services during an extended period, indirect losses are much
higher.
Functional breakdown is the main cause for service interruption in hospitals after a disaster; only
a small proportion of hospitals are put out of service because of structural damage. The measures to
prevent functional collapse require much less of an investment than preventing a building’s collapse.
However, the technology, policy, and management of hospital performance in disasters continue to be
a major challenge.
Natural disasters are not the only cause of functional and physical collapse of a facility and the re-
sulting deaths. Hospitals are built without taking into account natural hazards and when maintenance
is neglected, systems deteriorate over time. However, the vulnerability of health facilities can be reversed
through sustained political support, as has been shown in a variety of projects.
In designing new, safe hospitals, there are three safety objectives:
I) Protect the life of patients, visitors, and hospital staff,
II) protect the investment in equipment and furnishings, and
III) protect the performance of the health facility.
The aim of the Hospitals Safe from Disasters strategy is to ensure that hospitals will not only
remain standing in case of a disaster, but that they will function effectively and without interruption.
Emergencies require an increase in treatment capacity, and the hospital must be ready for optimal use
of its existing resources. The hospital must also ensure that trained personnel are available to provide
high quality, compassionate, and equitable treatment for disaster victims.

3 CD47/INF/4 Progress report on disaster preparedness and response to health disasters at national and regional levels www.paho.org/
English/GOV/CD/CD47-inf4-e.pdf.
4 UN/ECLAC. LC/MEX/L.291 Economic impact of natural disasters in health infrastructure. This report was presented at the Interna-
tional Conference on Disaster Mitigation in Health Facilities, Mexico D.F., 1996.
13
 HOSPITAL SAFETY INDEX 6

M
aking all health facilities safe in the event of disasters poses a major challenge for countries.
It is not only because of the high number of facilities and their high cost, but because there
is limited information about current safety levels in hospitals.
Hospitals represent more than 70% of public spending on health in Latin America and the Carib-
bean.5 Most of this spending is for specialized health personnel and sophisticated and costly equipment.
It is critical that hospitals continue to work in case of disaster. The public immediately goes to the clos-
est hospital for medical assistance in emergencies, without considering that these facilities might not be
functional owing to the impact of a natural event.
It is important, therefore, to identify the safety level of hospitals should a disaster occur. As part of
risk reduction strategy in the health sector, hospital evaluations aim to identify elements that need im-
provement in a specific hospital, and to prioritize interventions in hospitals that, because of their type or
location, are essential during and after a disaster.
Detailed vulnerability studies typically include in-depth analysis of hazards and structural, nonstruc-
tural, and organizational vulnerability. Each of these aspects requires the input of specialists who have
experience in disaster reduction. These vulnerability studies generally take several months to complete and
cost the hospital tens of thousands of dollars.
For that reason, the development of the Hospital Safety Index is a very important step toward the
goal of less vulnerable hospitals. The PAHO Disaster Mitigation Advisory Group (DIMAG) and national
experts came together to devise a method for quick and inexpensive evaluation of hospitals. A checklist
helps to assess different variables and safety standards for a hospital. A scoring system assigns the relative
importance of each variable, which, when calculated, gives a numeric value to the probability that a hos-
pital can survive and continue to function in a disaster.
The Hospital Safety Index not only estimates the operational capacity of a hospital during and after
an emergency, but it provides ranges that help authorities determine which facilities most urgently need
interventions. Priority might be given to a facility where the safety of occupants is determined to be at risk
during a disaster, or to a facility where equipment is at risk, or where maintenance is needed.
The safety index is not only a tool for making technical assessments, but it provides a new approach
to disaster prevention and mitigation for the health sector. It is not an “all or nothing” approach to hos-
pital safety, but allows for improvement in a facility over time. The index does not replace an in-depth
vulnerability assessment, but it helps authorities to quickly determine where interventions can improve
safety.

5 Pan American Health Organization. Transformation of hospital management in Latin America and the Caribbean, 2001.

15
 PROCEDURES AND RECOMMENDATIONS 7
FOR EVALUATING HEALTH FACILITIES

General coordination
The group responsible for general coordination is made up of professionals at the decision-making
level from relevant agencies (Ministry of Health, Social Security, etc.) who initiate the evaluation process
in each institution. This group will calculate the safety index, gather data, and develop and maintain
databases, among other duties. They are also responsible for selecting and training evaluators, forming
the evaluation teams, and facilitating the first contact between the evaluation team and representatives
of the institution being evaluated.
The general coordination group has overall responsibility for carrying out recommendations of
the evaluation team in terms of improvements to a facility. The group is responsible for overseeing the
safety of the health network in general in case of disasters. It participates in strategic decision-making
and developing plans, programs, and policies for the welfare of the health service network in case of
disasters.

Membership and responsibilities of the evaluation team

Evaluators should be professionals who work in the areas of health facility construction, providing health
services, administration, or hospital support activities (e.g., maintenance). If possible, evaluators should have
at least five years of experience in structural design, construction, and/or hospital management in disasters.
When people with this background are not available, professionals with less experience or students at an
advanced level in equivalent fields of study may be selected. Evaluators with less experience should be super-
vised by national and/or international experts in the subject. In either case, the aim is for expert observation
in evaluating elements of the hospital.
The evaluation is conducted by a multidisciplinary team, preferably including:
• engineers with training in structural engineering,
• architects with training in hospital design,
• specialists in hospital equipment and/or electrical and mechanical maintenance,
• health care professionals (doctors, nurses, etc.),
• specialists in planning and/or administration and logistics,
• others (security specialists, municipal inspectors, etc.)
It is important to consider the needs of the facility and its position in the hospital network when
forming the evaluation team. For example, geotechnical engineers or engineers specializing in seismic
resistance should be part of the team evaluating health facilities located in seismic zones.

17
Hospital Safety Index GUIDE FOR EVALUATORS

The size and number of teams can vary according to the complexity of the facility. The team should
request the advice of specialists when necessary.
All professionals involved in the process receive training in the objectives and methodology of the
safe hospitals evaluation, filling out the Safe Hospitals Checklist, interpretation of results, and preparation
of a final report.

Organization of the evaluation team

Once the health facility is chosen, the evaluation team is formed, taking into account features of the
facility and its surroundings. Each team must have a coordinator. Besides his or her own official identifica-
tion, each evaluator must have identification that accredits them as part of the evaluation team. This will be
part of their certification after completing the training course for safe hospitals, as established by the general
coordination group.
Team coordinator: is designated by the appropriate authority or chosen by the evaluation team. Ideally,
the team coordinator will have prior experience in risk reduction and disaster response as well as experience
in assessing hospitals for safety in disaster situations, preferably using this methodology.
The team coordinator responsibilities are to arrange pre-evaluation interviews with hospital personnel
in order to finalize evaluation arrangements. If necessary, will arrange for the team’s transport, lodging, and
security, and procure the materials and tools needed for the evaluation. He must provide documentation
from other facilities that is pertinent to the evaluation, organize interviews with staff from different divisions
of the health facility, and organize sub-groups, as necessary, for the evaluation.
As part of his operative responsibilities, the coordinator must provide evaluation team members with
copies of the Safe Hospitals Checklist and collect them when comments and recommendations have been
made. He should track the process until formal presentation of the evaluation is made to facility authorities,
and make contact with national and/or international experts should the team want assistance.
Evaluators: The evaluators’ responsibilities are to inspect the structure, to collect and analyze relevant
documentation, to collaborate in filling out the forms, and to provide technical input in the final recom-
mendations and in calculations of the Hospital Safety Index. Each evaluator is responsible for completing an
evaluation form. Where a sub-group makes an assessment, evaluators in that sub-group will complete only
the section of the form that corresponds to their assignment. Evaluators are responsible for consolidating the
information and modifying it in accordance with results of the first meetings following the evaluation.
A high level of ethical and cordial behavior is expected from team members. The results of the evaluation
report are to be treated as confidential. Under no circumstances will an evaluator discuss the results of the evaluation
with outside parties.
Evaluators must not interfere in the daily operations of the facility. He or she must not handle equip-
ment or give advice to staff on matters having to do with operations. The evaluator should take safety mea-
sures during the evaluation and wear personal protective gear when appropriate.
It is expected that the evaluator will dedicate himself or herself to the evaluation for the time required.

18
 PROCEDURES AND RECOMMENDATIONS FOR EVALUATING HEALTH FACILITIES

Equipment and materials

The following equipment and materials will be needed during the evaluation:
• Guide for Evaluators of Safe Hospitals (this document)
• Map of the area surrounding the health facility
• Natural hazard map(s)
• Plan of the health facility
• Forms (Form 1: General information; Form 2: Safe Hospitals Checklist)
• Notebooks, pencils, pens
• Two-way radio or cell phone
• Directory of key personnel involved in the evaluation
• Flashlights with charged batteries
• Still camera, video camera, tape recorder (optional)
• Light tools (measuring tapes, chisels, etc.) (optional)
• Calculator (optional)
• Other tools considered necessary for technical assessment
Evaluation team members should carry with them:
• Personal identification
• Evaluation team accreditation
• Comfortable and appropriate work clothing
• Necessary protective items (helmet, protective glasses, etc.)

Role of the Hospital Disaster Committee in the evaluation

The members of the Hospital Disaster Committee should be present throughout the evaluation pro-
cess, as well as hospital authorities and personnel who are involved in decision-making or who have vital
information about the elements being evaluated.
In terms of the evaluation, the main responsibilities of the Hospital Disaster Committee are: to pro-
vide all documentation needed to carry out the evaluation; to cooperate in the inspection of the structure
by demonstrating or explaining the actual situation and facilitate an accurate diagnosis; to support the
diagnosis process with comments and evidence; and to facilitate participation of key hospital personnel
through interviews and or meetings about the evaluation. Everyone should keep in mind that the objec-
tives of the evaluation process are to take the necessary steps to reduce risk, mitigate damage from disas-
ters, and create social awareness about disaster prevention.
The Hospital Disaster Committee (also known as, for example, the “Emergency and Disaster Com-
mittee” or “Risk Management Committee”) is the hospital entity responsible for articulating, directing,

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Hospital Safety Index GUIDE FOR EVALUATORS

assessing, and coordinating hospital activities for the periods before, during, and after a disaster, ensuring
the participation of all hospital workers. The structure of this committee should reflect that of the particu-
lar facility, but in general should have the following membership:
• Hospital director
• Director of administration
• Chief of emergency unit (coordinator)
• Chief of nursing
• Medical director
• Chief of maintenance and transportation
• Chief of security
• Labor union representative
• Community representative
• Other hospital personnel as deemed necessary.
This committee’s main task is to guide the development and execution of a plan that integrates
management of risk and of disaster and emergency response. Among other responsibilities, the committee
determines the hospital’s internal disaster response standards and functions, oversees permanent training
and education for staff, and promotes cooperation and integration with the community it serves.
The by-laws of the Hospital Disaster Committee should be formalized before the evaluation process
begins.

Initial inspection of surroundings

First, the evaluators make a preliminary inspection of the city or area where the facility is located.
This provides an overview of the architectural and construction features of the city, the type of damage
that natural hazards could cause, and the areas that would probably be most affected. The evaluators will
become familiar with primary and alternate routes used to access the hospital.
During the initial inspection, the team gathers pertinent documentation from different sources,
including fire services, the police, and other community services. All of this information is included in
the final report.
Next is inspection of the hospital exterior. This involves filling out the forms that identify the build-
ing and type of structure, construction quality, irregularities, and general condition, including the condi-
tion of facings, balconies, ledges, etc. The condition of neighboring structures is documented, and evalu-
ators determine whether outside evacuation areas are safe.
The team identifies irregularities in the terrain, (for example whether there are steep slopes nearby)
and any large bodies of water (ocean, rivers, lakes) near the hospital that could elevate the ground water
level.

20
 PROCEDURES AND RECOMMENDATIONS FOR EVALUATING HEALTH FACILITIES

Using the Checklist

When the process of using the checklist begins, it is important to consider the time required to com-
plete the evaluation, the availability of all interested parties (evaluation team, members of the Hospital
Disaster Committee, others), as well as any hospital requirements (shifts, treatment hours, patients, etc.).
The evaluation should be interactive and dynamic and have input from the members of the Hospital Di-
saster Committee, members of the evaluation team, and outside parties (municipal and health authorities)
as deemed necessary.
Elements to be evaluated are grouped into modules. Calculation of the safety index is weighted dif-
ferently for individual modules, depending on their importance to the overall safety of the hospital. For
example, a deficiency in a structural element will not be weighted the same as a deficiency in a nonstruc-
tural element.
Modules can be evaluated individually or together, but finally, they must be integrated to obtain a
single measurement.
The organization of the evaluation should take into account the strategic aspects of the evaluated
institution and its surroundings, so that “evaluating teams” can be put together, including the number of
groups and the specialization of the experts needed.
The on-site evaluation of the facility should take no more than eight hours. However, time must also
be scheduled for organizational meetings prior to the evaluation. These meetings should be arranged to
include members of the evaluation team, representatives from the Ministry of Health or Social Security
agency responsible for the facility, the management staff of the hospital, and members of the commu-
nity.
The evaluation team is divided into subgroups, each having a different focus. The composition of
subgroups is determined by features of the facility and its surroundings. Each subgroup should have at
least two people, each having expertise in certain areas of the evaluation.
It is advisable to take photographs to obtain as much documentation during the evaluation as pos-
sible, and with authorization from the facility administration, to use recording cameras and voice record-
ers. However, this equipment should not be used if it intimidates interviewees in any way or lessens the
level of confidence between evaluators and facility staff.
Each question in the checklist must be answered unless there is an indication that an answer can be
left blank. Sampling questions is not allowed. If there is doubt about rating an element, it is preferable to
give a lower than a higher safety rating. Any element classified as having a low level of safety will be given
priority for attention.
During the process of completing the checklist, evaluators should not make comments about opera-
tions in the facility, unless specifically addressed in the evaluation. Value judgments expressed by indi-
vidual evaluators or the group are not considered part of the evaluation.
Evaluators should make notes about their observations in the column reserved for comments in the
checklist, in the row pertaining to an element. These comments are helpful when compiling the evalua-
tion report. While they do not form part of the numerical calculations of the safety index, comments are
included in the recommendations for the facility that are made by evaluators. In the comments section

21
Hospital Safety Index GUIDE FOR EVALUATORS

an evaluator might justify a positive or negative rating, include questions raised by the facility about a
response in the checklist, or emphasize urgent measures that should be taken to improve the hospital’s
safety. The comments section can also include general references to the facility that are not included in the
evaluation modules or that might warrant another opinion.
The evaluation and comments must be made in the local language. Any translations of the material
must be faithful to the meaning of the content.
Once the evaluation is completed, the facility being evaluated has the opportunity to add general
comments regarding the process and the evaluation team. This feedback is essential for improving the
evaluation process.
Recommendations are the responsibility of the general coordination, who should present them in
writing in the final report.

Finalizing the evaluation

Once the on-site evaluation is complete, the evaluation team meets to share, consolidate, and dis-
cuss their findings. Following this, a meeting is organized which includes all interested parties, whether
or not they were directly involved in the evaluation. Members of team subgroups will make general
observations about the data collected at this meeting. Subsequent discussion and suggestions will be
used to make changes to the evaluation documents, or comments can be noted.
When there is disagreement between the evaluation team and the hospital disaster committee or
administration of the hospital, it should be noted as an observation to the evaluation.
The corrected document is signed and dated by members of the evaluation team, and a copy is
delivered to the director of the facility. The original report with any additional documentation (pho-
tographs, documents, recordings, etc.) is delivered to the general coordination group. They, in turn,
are responsible for filing all documentation, updating the database of the tabulated results of hospital
assessments, and calculating the safety index. The general coordination group prepares the final report
which includes recommendations made by the evaluation team.
The report should be presented at the final meeting, where feedback is expected from the evalu-
ated institution regarding the general evaluation process, so that improvements can be made in future
evaluations.
Following the presentation of the final report to the facility, the next stage of tasks and respon-
sibilities for both groups will emerge. The general coordination group must diligently follow-up with
inspections of the measures deemed necessary to improve the facility’s safety index. The hospital that
was evaluated must carry out necessary improvements in the times recommended. The hospital must
then inform the general coordination group and proceed to final inspections, if this step has been
agreed upon.
A copy of the final report will be filed by the coordination group along with supporting documen-
tation in a file identified with the name of the facility, and subdivided into dates of evaluations. The
database will be updated and dates will be agreed on for the follow-up process.

22
 BRIEF DESCRIPTION OF 8
THE EVALUATION FORMS

Form 1: “General information about the health facility”

This form includes general information about the health facility being evaluated and its treatment
capacity.
• General information: Name and address of the facility, contact numbers, names of administra-
tors, number of beds, hospital occupancy rate, number of personnel, diagram of the facility
and its surroundings, position in the health services network of the area, number of persons
treated, others.
• Treatment capacity: number of beds by services or surgical and medical specialty; expansion
capacity in case of disaster.
This form should be completed before the evaluation by the hospital’s disaster committee. If pos-
sible it should be accompanied by a diagram of the hospital setting and the distribution of services, with
a legend describing them.

Form 2: “Safe Hospitals Checklist”

The checklist is used for preliminary diagnosis of the hospital’s safety in the event of disasters. It
contains 145 variables, each of which has three safety levels: low, medium, and high.
It is divided into four sections or modules:
1. Geographic location of the health facility
2. Structural safety
3. Non-structural safety
4. Functional capacity

Issues to keep in mind while using the checklist are as follows:

a. The contents of the checklist and the elements being evaluated are formulated for application
in general or specialized hospitals.
b. The component on geographic location is for determination of the hazards that exist in the
area; these hazards are not included in the calculation of the safety index.
c. Modules 2-4 have values that are weighted differently in accordance with their significance in
the event of a disaster. The values for structural components represent 50% of total values in
the index, nonstructural components represent 30% and functional capacity represents 20%.
d. Each item has different importance in relationship to other items in the same module. Items
with the most relevance are shaded or highlighted and are weighted more heavily than other
items.

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 e. The values assigned to each variable are in accordance with established standards (for example,
PAHO manuals, local construction codes, and institutional standards and rules).
f. Criteria are applied most strictly in the critical areas of the hospital where the demand for
treatment is greatest in an emergency
g. For the evaluation process to be considered complete, all items must be analyzed.
h. The checklist includes instructions for filling in each of the items. Only one box for each item
being evaluated should be marked with an “X” (low, medium, or high) for safety level, level of
organization, level of implementation, or level of availability.

Four modules of the checklist

1. Geographic location of the health facility
The first module allows for a rapid description of hazards or dangers and geotechnical properties
of soils at the site of the health facility.
This information should be taken into account when determining safety levels of the elements in
the other modules.

2. Structural safety
Evaluating structural safety of the facility involves assessment of the type of structure, materials, and previ-
ous exposure to natural and other hazards. The objective is to determine if the structure meets standards for
providing services to the population even in cases of major disaster, or whether it could be impacted in a way
that would compromise structural integrity and its functional capacity.
Safety in terms of prior events involves two elements. The first is whether the facility has been exposed to
natural hazards in the past, and its relative vulnerability to natural hazards. Second, the evaluators must deter-
mine how the facility was impacted or damaged in the past and how the damage was addressed.
The evaluators attempt to identify potential risks in terms of the type of design, structure, construction
materials, and critical components of the structure.
Structural systems and the quality and quantity of construction materials provide the stability and resis-
tance of a building against natural forces. Making adjustments in a structure for a given phenomenon is essen-
tial, since a structural solution can be valid for hurricanes but not for earthquakes.

3. Non-structural safety
The failure of non-structural elements does not usually put the stability of a building at risk, but it
can endanger people and the contents of a building. Evaluators determine whether these elements could
separate, fall, or tip which could have an impact on important structural elements. Evaluators will verify
the stability of non-structural elements (provided by, for example, supports, anchors, and secure storage)
and whether equipment can function during and after a disaster (for example, whether there are safety
valves for reserve water tanks and alternative connections to networks, etc.). This analysis includes the

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 BRIEF DESCRIPTION OF THE EVALUATION FORMS

safety of critical networks (for example, the water system, power, communications); heat, ventilation, and
air conditioning (HVAC) systems in critical areas; and medical diagnostic and treatment equipment.
Architectural elements such as facings, doors, windows, and cantilevers are evaluated to determine
their vulnerability to water and the impact of flying objects. Safety of access to the facility and internal and
external traffic are taken into account in this section, along with lighting systems, fire protection systems,
false ceilings, and other components.

4. Safety based on functional capacity

How hospital personnel are organized to respond in disaster situations is central to evaluating a
hospital’s capacity to function during and after a disaster. This module looks at the general organiza-
tion of hospital management, implementation of disaster plans and programs, resources for disaster
preparedness and response, level of training and disaster preparedness of the staff, and the safety of the
priority services that allow the hospital to function. The hospital administrators should provide evalua-
tors with any documentation that is relevant to their hospital disaster plan.

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 HOW TO CALCULATE THE 9
HOSPITAL SAFETY INDEX

Safety Index Calculator

The first step in calculating the Hospital Safety Index is to carry out the evaluation and complete
the checklist process, which evaluates the health facility’s location, structural and nonstructural safety,
and organization of hospital staff.
We should point out that the hazard levels assigned to the location of the hospital, including the
level of hazard due to soil characteristics, are not counted when calculating the Safety Index.
The second step is to enter the results from the checklist into the Safety Index Calculator, which is
a page that has a series of formulas that assign specific values to each variable. The calculations are based
on how the evaluators rated each element and the relative importance of that element to overall safety of
the hospital in case of disaster. This spreadsheet is referred to as the Hospital Safety Index Calculator.

Relative weight of variables, sections and components

Variables or elements are grouped into sub-modules, and a group of sub-modules constitutes one
module.
The value of each variable is multiplied by its relative weight in a sub-module. The sum of values of
all the variables of a sub-module gives 100% of that sub-module.
Each sub-module is weighted in relation to the other sub-modules in the same module. The sum of
the weighted values of the sub-modules gives 100% of the respective module.
Because it is possible to separate the results for sub-modules and for modules, it is easier to identify
the critical areas of the hospital.
As mentioned earlier, the module for structural safety has a weighted value of 50% of the index, the
nonstructural module has a weighted value of 30%, and functional capacity is weighted at 20%.
The sum of the weighted results of the three modules gives a hospital safety rating expressed as the
probability (percentage) that a facility will be able to function in a disaster situation.
Given that each variable has three levels of safety (high, average, and low), and to avoid any distor-
tion at the time of evaluation, each level of safety receives a constant value. The Safety Index has a maxi-
mum value of 1 (one) and a minimum of 0 (zero).
Calculations and weighted values take into account that it is very difficult for a hospital to remain
perfectly operational, so it is rare for a facility to be given a safety index of “1.”

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Hospital Safety Index GUIDE FOR EVALUATORS

Entering data into the Safety Index Calculator

When formulas are applied to the data from the checklist, values are assigned to each item, and weight-
ed values are assigned to each sub-module and to each module. The formulas calculate the overall safety index
and a specific value for the structural, non-structural, and organization/functionality modules.
The checklist results are entered as number “1” in the corresponding cells and the calculation page
automatically applies a series of formulas to carry out the following steps:
• Automatically corrects input errors
• Assigns weighted values for the safety of each variable, each sub-module, and each module
(structural, non-structural, and functional)
• Calculates and graphs relative safety for each module (percentage)
• Calculates and graphs the Hospital Safety Index
• Automatically classifies the hospital with “A”, “B”, or “C” (see the following graphic)
• According to the hospital safety classification, provides general recommendations about how
to correct deficiencies.

General recommendations for intervention

Safety index Classification What should be done?

Urgent intervention measures are needed. The hospital’s current
0 – 0.35 C safety levels are inadequate to protect the lives of patients and
hospital staff during and after a disaster.
Intervention measures are needed in the short-term. The hospi-
tal’s current safety levels are such that patients, hospital staff, and
0.36 – 0.65 B its ability to function during and after a disaster are potentially at
risk.
It is likely that the hospital will function in case of a disaster. It is
recommended, however, to continue with measures to improve
0.66 – 1 A response capacity and to carry out preventive measures in the
medium- and long-term to improve the safety level in case of
disaster.

The evaluator should interpret results in the context of other health facilities in the area’s health
service network, the location of the facility, and the type of population it serves.

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 INSTRUCTIONS TO COMPLETE 10
THE CHECKLIST

Before applying the check list, make sure that the previous steps described in the proceedings and
recommendations for the evaluation of the health facility have been completed.
In this section each one of the 145 aspects or variables to be evaluated are described and guidance
is provided as to how best to establish the corresponding degree of safety: High (H), Average (A) or
Low (L). All of the variables need to be evaluated and assessed and the result of the evaluation should
be noted down in the check list.
The degree of safety will be evaluated in accordance with the standards established for each vari-
able and the individual and collective experience of the group of evaluators. It is recommended that ad-
ditional information or comments on the variable assessed should be noted in the observations column.
Take into account that some variables include a note in capital letters which indicates the possibility
that it may not be possible to evaluate this variable and as a result, this could be left blank, with no
answer. Even in these cases, careful analysis is recommended to reconfirm that the condition described
in capital letters is fulfilled before leaving this blank and evaluating the following variable.
On completion of each module in the check list: Geographical location, structural safety, non-
structural safety and functional capacity, comments or general observations should be noted as well as
the name and signature of the evaluators.

I. Geographic location of the health facility

Analysis of the geographical location of the facility enables hazards to be assessed in relation to
previous emergencies and disasters which have occurred in the zone, and the place and type of land
where the health facility has been constructed. Natural and anthropogenic hazards should be taken into
account. This aspect is divided into two categories: Hazards and geotechnical properties of the soil.
The hospital disaster committee should be requested to provide in advance the map or maps which
specify the hazards in the zone. Should there be no maps, other local entities should be approached,
such as multi-sectoral risk reduction bodies, for example, the Civil Protection or Defence, the Emer-
gency Commission etc.
It is necessary to analyze this information to evaluate the safety of the facility in its surroundings
in relation to hazards. This is fundamental for the evaluation team and the hospital committee since
they will set the boundaries of the evaluation in respect of the following points, correcting setting out
“the factors against which the facility should be safe”, given the frequency, magnitude and intensity of
destructive phenomena (hazards) and the geotechnical properties of the soil.
This point of the evaluation does not lend itself to measurement; nor does it form part of the
calculation of the hospital safety index. Nevertheless, it is useful to asses each one of the variables ap-
propriately, taking into account the surroundings and the context of the area in which the hospital is
located.

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Hospital Safety Index GUIDE FOR EVALUATORS

1.1 Hazards
Under this point, the different types of hazards are analyzed (geological, hydro-meteorological, so-
cial, environmental, chemical and technical) related to the location where the health facility is located.
The extent of the hazard to which the hospital is exposed is considered to be directly proportional to
the probability of the occurrence of a hazard and its magnitude.
In this way, they can be classified as high (high probability of a hazard taking place or high-mag-
nitude hazard), medium (high probability of a moderate hazard) and low (low probability or a hazard
of low magnitude).
Refer to hazard maps. Request the Hospital Disaster Committee to provide the map(s) showing
safety hazards at the site of the building.

1.1.1 Geological phenomena

• Earthquakes
Rate the hazard level of the hospital in terms of geotechnical soil analyses.
• Volcanic eruptions
Refer to hazard maps of the region to rate the hospital’s exposure to hazard in terms of its proximity
to volcanoes, volcanic activity, routes of lava flow, pyroclastic flow and ash fall.
• Landslides
Refer to hazard maps to rate the level of hazard for the hospital in terms of landslides caused
by unstable soils (among other causes).
• Tsunamis
Refer to hazard maps to rate the level of hazard for the hospital in terms of previous tsunami
events caused by submarine seismic or volcanic activity.
• Others (specify)
Refer to hazard maps to identify other geological phenomena not listed above. Specify the
hazard and rate the corresponding hazard level for the hospital.
1.1.2 Hydro-meteorological phenomena
• Hurricanes
Refer to hazard maps to rate the hazard level of the hospital in terms of hurricanes. It is helpful
to take into account the history of such events when rating the hazard level of the facility.
• Torrential rains
Rate the hazard level for the hospital in relation to flooding due to intensive rainfall based on
the history of such events.
• Storm surge or river flooding
Rate the hospital’s level of exposure to storm surge or river flooding hazards based on previous
events that did or did not cause flooding in or around the hospital.

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 INSTRUCTIONS TO COMPLETE THE CHECKLIST

• Landslides
Refer to geological maps to rate the hospital’s level of exposure to landslide hazards caused by
saturated soils.
• Others (specify)
Refer to hazard maps to identify other hydro-meteorological hazards not listed above. Specify
the hazard and rate the corresponding hazard level for the hospital.
1.1.3 Social phenomena
• Population gatherings
Rate the hospital’s exposure to hazard in relation to the type of population it serves, its proxim-
ity to population gatherings and prior events that have affected the hospital.
• Displaced populations
Rate the hospital’s exposure to hazard in terms of people who have been displaced as a result
of war, socio-political circumstances, or due to immigration and emigration.
• Others (specify)
If other social phenomena affect the safety of the hospital, specify them and rate the level of
hazard for the hospital accordingly.
1.1.4 Environmental phenomena
• Epidemics
With reference to any past incidents at the hospital and specific pathogens, rate the hospital’s
exposure to hazards related to epidemics.
• Contamination (systems)
With reference to any past incidents involving contamination, rate the hospital’s exposure to
hazards from contamination of its systems.
• Infestations
With reference to the location and past incidents at the hospital, rate the hospital’s exposure to
hazards from infestations (flies, fleas, rodents, etc.).
• Others (specify)
With reference to any past incidents at the hospital specify any other environmental phenom-
ena not included above that might compromise the level of safety of the hospital.
1.1.5 Chemical and/or technological phenomena
• Explosions
With reference to the hospital’s surroundings, rate the hospital’s exposure to explosion hazards.
• Fires
With reference to the exterior of the hospital building, rate the hospital’s exposure to external
fires.

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Hospital Safety Index GUIDE FOR EVALUATORS

• Hazardous material spills

With reference to the hospital’s surroundings, rate the hospital’s exposure to hazardous mate-
rial spills.
• Others (specify)
Specify and rate other chemical or technological hazards in the area where the hospital is
located.

1.2 Geotechnical properties of soils

Under this point, the aim is to have a general idea of the soil mechanics and the geotechnical pa-
rameters as well as the levels of foundation inherent to the soil type.
• Liquefaction
With reference to the geotechnical soil analysis at the hospital site, rate the level of the facility’s
exposure to hazards from saturated and loose subsoil.
• Clay soils
With reference to soil maps, rate the hospital’s exposure to hazards from clay soil.
• Unstable slopes
Refer to geological maps and specify the hospital’s exposure to hazards from the presence of
slopes.

II. Elements related to structural safety of the building

Addresses the elements related to the first of the three modules or components which are taken
into account to calculate the safety index: the structural safety of the building
Columns, beams, walls, floor slabs, foundations, etc., are structural elements that form part of the
load-bearing system of the building. This checklist was developed specifically to evaluate buildings of
reinforced concrete. The aspects addressed in this structural module should be assessed by structural
engineers; therefore, the sub-group which undertakes the assessments in this module should preferably
be coordinated by a structural engineer.
The module on structural safety is divided into two sub-modules:
1. Prior events affecting hospital safety
2. Safety of the structural system and type of materials used in the building
Classifications will be “High”, “Average”, and Low”.

2.1. Prior events affecting hospital safety

This corresponds to sub-module 2.1 and is made up of 3 items or rows in the checklist (developed
under items 1 to 3).

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 INSTRUCTIONS TO COMPLETE THE CHECKLIST

1. Has there been prior structural damage to the hospital as a result of natural
phenomena?
The evaluators will determine whether structural reports indicate that the level of safety has been
compromised in the past by a natural phenomenon.
To get historical accounts of damage to the facility, it is important to interview personnel who
have worked the longest in the hospital, no matter their position. Cleaning personnel, kitchen staff, ad-
ministration, or support staff can relate their experiences in the hospital during disasters in the past. Ask
specifically about structural damage they might have observed. Most people remember damage to non-
structural elements, which are usually numerous. If the hospital has suffered recent damage, it is likely
that there are published accounts of the event. Certain reports might be accessible on the Internet.
In some cases the question does not apply to the facility because a variable does not exist. Only in
such cases, and where there are instructions to leave boxes blank if the question does not apply, should
the question not be answered.
The safety index has a special formula for calculating elements that are not applicable. When rat-
ings from the checklist are entered, only the elements that have been evaluated are calculated.

IF SUCH AN EVENT HAS NOT OCCURRED IN THE VICINITY

OF THE HOSPITAL, LEAVE BOXES BLANK.

Safety ratings for item No. 1 are: Low = Major damage; Average = Moderate damage; High =Minor
damage.

2. Was the hospital built and/or repaired using current safety standards?
The evaluator will verify whether the building has been repaired, the date of repairs, and whether
repairs were carried out using standards for safe buildings. Once the date of repairs is established, it will
be possible to determine what construction standards were in force when repairs were made.
As mentioned earlier, elements that are highlighted in the checklist are particularly important
for the evaluation, which is the case for this question. Evaluators should make an in-depth assess-
ment of prior construction work in the facility. They should interview a variety of people, particularly
maintenance staff who have experience in the facility, and, if possible, the people responsible for the
construction.
Safety ratings for Item No. 2 are: Low: Current safety standards not applied; Average = Current safety
standards partially applied; High = Current safety standards fully applied.

3. Has remodeling or modification affected structural behavior of the facility?

The evaluators should determine whether modifications were carried out using safe building stan-
dards. Frequently, hospitals “suffer” modifications that different departments and services need. These
changes may be made without considering what effect they will have on the structure’s resistance to

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Hospital Safety Index GUIDE FOR EVALUATORS

hazards or future events, increasing vulnerability for the facility and its occupants. For example, filling
in an open space between two columns with a masonry wall redistributes loads in a building. A modi-
fication such as this could cause columns to fail.
Safety ratings for item No. 3 are: Low = Major remodeling or modifications have been carried out;
Average = Moderate remodeling and/or modifications; High = Minor remodeling and/or modifications or no
modifications were carried out.

2.2. Safety of the structural system and type of materials used in the building
This second aspect to be assessed in the structural module corresponds to sub-module 2.2 and is
made up of 10 items or rows in the checklist developed under items 4 to13.

4. Condition of the building

Evaluators will inspect the building for signs of deterioration, such as broken plaster, cracks, or
sinking structural elements, and determine the causes. It is important to interview the hospital’s main-
tenance staff in this regard. When assessing any damaged structural elements evaluators should de-
termine their function in maintaining overall structural stability. For example, the risk posed by a
damaged column on the ground floor is not the same as for one on the top floor. The condition of the
building is closely related to the type of construction materials used for structural elements. A crack
can occur because of a variety of things, some indicate something serious (design, overload) and others
do not (change in volume). It is also important to assess the location of the cracks and their angle to
determine the condition of the building.
Safety ratings for item No. 4 are: Low = Deterioration caused by weathering; cracks on the first floor
and irregular height of buildings; Average = Deterioration caused only by weathering; High = Good; no
deterioration or cracks observed.

5. Construction materials used

This item is closely related to item 4 (“Condition of the building”). For example, when the struc-
ture is built primarily with reinforced concrete, which is an excellent material, the presence of cracks
and rust can indicate that incorrect amounts of concrete components (cement, rock, sand, and water)
were used. As a result, permeability may be high and the resistance of materials low, which increases the
vulnerability of these elements and puts the structure as a whole at risk. The evaluators should indicate
whether the elements in poor condition are of structural value to the hospital building.
Regarding rusting iron and cracks in concrete, one or both of these conditions may be present.
For example, concrete forms may show signs of rust, but cracks may or may not have evidence of
oxidation.
Safety ratings for item No. 5 are: Low = Rust with flaking; cracks larger than 3mm; Average = Cracks
between 1 and 3 mm or rust powder present; High = Cracks less than 1 mm; no rust.

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 INSTRUCTIONS TO COMPLETE THE CHECKLIST

6. Interaction of non-structural elements with the structure

In extreme conditions non-structural elements, because of their weight and rigidity, can affect the
behavior of structural elements, putting the stability of a structure at risk. The evaluators must determine
whether non-structural elements are completely tied to the structure, if “short columns” are present, if
joints are flexible, and whether expansion joints have been used. An example of non-structural/structural
interaction is as follows: a non-structural dividing wall falls during an earthquake because of a bad an-
chor; the wall falls onto a staircase beam, obstructs the staircase and, in the worst case, destroys it.
Safety ratings for item No. 6 are: Low = separation of less than 0.5% of the height of the partition/
joint; Average = separation between 0.5 and 1.5% of the height of the partition/joint; High = separation
above 1.5% of the partition/joint.

7. Proximity of buildings (hazards of pounding, wind tunnel effects, fires, etc.)

Buildings that are closely spaced can cause different problems depending on the forces that affect
them. For example, in the case of an earthquake, buildings that are too closely spaced, depending on
their heights, can pound against each other until one or both collapse. In the case of hurricanes, there
are wind tunnel effects between closely spaced buildings. Pressure from the wind can build around
certain sections of a structure, placing much greater force than the load for which a multi-story build-
ing was designed. Evaluators should inspect the exterior of the hospital to determine whether such
problems might arise.
Safety ratings for item No. 7 are: Low = Separation is less than 0.5% of the height of the shorter of two
adjacent buildings; Average = Separation is between 0.5% and 1.5% of the height of the shorter of two adja-
cent buildings; High = Separation is more than 1.5% of the height of the shorter of two adjacent buildings.

8. Structural redundancy
Redundancy is a normal part of structural systems, and is essential for the safety of hospital buildings. The
evaluation aims to ensure that the hospital can resist the lateral forces caused by earthquakes and in major hur-
ricanes in the two main orthogonal directions of the building.
Evaluators will review structural plans of the hospital building and verify at the site whether the structure
actually meets the design criteria in the two principal orthogonal directions. A building with fewer than three
lines or axes of resistance in any of the major directions is vulnerable to major demands of resistance and rigid-
ity.
While not one of the items in the checklist, evaluators should be aware that the three lines of resistance do
not guarantee structural redundancy in rigid-framed buildings, with structural beams and/or walls, and with
good beam-column connections. In some cases it will be necessary to evaluate structural safety of other designs
such as flat slab with flat beams and note the safety level.
Safety ratings for item No. 8 are: Low = Fewer than three lines of resistance in each direction; Average = Three
lines of resistance in each direction or lines without orthogonal orientation; High = More than three lines of resistance
in each orthogonal direction of the building.

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Hospital Safety Index GUIDE FOR EVALUATORS

9. Structural detailing, including connections

Joints for structural components are among the most critical design elements for lateral loads, especially
when caused by earthquakes. Notwithstanding the construction year of the building, the evaluator should try
to determine characteristics of joints both through on-site observation and by reviewing structural plans, and
develop clear-cut criteria for them, especially in seismic areas. When dealing with prefabricated construction,
the evaluator must do a detailed examination of the joints; they will be numerous, not monolithic, and in most
cases welded or wet joints. They should be assessed for cracks or fractures, which would put the joints and,
ultimately, the structure at risk.
Safety ratings for item No. 9 are: Low = Built before 1970; Average = Built between 1970 and 1990;
High = Built after 1990 and according to standards.

10. Safety of foundations

Foundations are the most difficult structural elements to evaluate because they are neither acces-
sible nor visible. And to add to this difficulty, corresponding plans for the foundations are often not
available. If the facility is old the plans might not be in the archived either in the administration or
maintenance department. In some cases the plans may be with a construction company that has done
studies for the purpose of expansion, remodeling, or repairs.
It is important to make every effort to access the plans to have precise criteria for the foundation,
to determine the type of foundation (shallow, deep, isolated, combination, etc.) and whether they are
united or isolated. Buildings are more vulnerable to seismic forces when they do not have braced beams
connected to the foundation.
When evaluating this item it is important to take into account the information about soils at the
site from the sub-module 1.2 “Geographic location of the hospital” to determine soil-structure interac-
tions. The ground water level and type of soil at the building site play a critical role in determining the
facility’s vulnerability to floods and differential settlement of the foundation, with the well-understood
effects on vertical structural elements. Liquefaction can occur if the building is on saturated, unconsoli-
dated soils, as in the case of sand beds, saturated silt, or uncompacted fill, among others. Liquefaction
has caused severe damage to infrastructure, and the evaluator should carefully substantiate whether
such conditions are present at the hospital site.
Safety ratings for item No. 10 are: Low = Information is lacking or foundation depth is less than 1.5
m; Average = Plans and soil studies are lacking but foundation depth is more than 1.5 m; High = Plans, soil
studies are available and foundation depth is more than 1.5 m.

11. Irregularities in the plan (rigidity, mass, and resistance)

Irregular structures can be expressed in terms of shape, configuration, and torsional eccentricity (i.e.,
the distance between the center of mass and the center of rigidity). While evaluators inspect the exterior
and interior of the hospital, they should look for inconsistencies in the hospital plan from the perspective
of rigidity (shape and type of materials used for resistant vertical elements) as well as the distribution of
mass (concentrated and distributed). The evaluator should try to identify at the site and by using diagrams
whether there are seismic joints that divide the structure into regular parts, or whether irregular con-

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 INSTRUCTIONS TO COMPLETE THE CHECKLIST

figurations are present, such as L-shaped, T-shaped, U-shaped, or cruciform plans, or more complicated
configurations.
Another aspect that the evaluator must check is the relative position of the frames (framework of
beams and columns) and the shear walls since this determines the response of horizontal diaphragms
(slabs) in terms of displacement and rotation. The presence of large openings in horizontal diaphragms
due to interior patios or for access to stairs and elevators make the structure more vulnerable to lateral
loads caused by earthquakes and intense hurricanes. During extreme phenomena such as earthquakes or
high winds, poorly distributed mass can cause excessive loads in some areas of a structure, resulting in its
collapse. The evaluator should determine if these conditions exist and whether there are structural ele-
ments designed to mitigate these effects.
Safety ratings for item No. 11 are: Low = Shapes are irregular and structure is not uniform; Average =
Shapes are irregular but structure is uniform; High = Shapes are regular, structure has uniform plan, and there
are no elements that would cause torsion.

12. Irregularities in height (rigidity, mass, and resistance)

In elevation of a hospital building, as in the case of the plan, irregularity can be found in shape,
configuration, and torsional eccentricity. As in item No. 11, the evaluator must take note of any abrupt
changes in configuration. The narrowness of the building (height to width ratio) in the principal or-
thogonal directions, can give an idea of the building’s ability to withstand vibrations generated by
lateral loads caused by earthquake and wind forces. The evaluator should check differences in height
between the floors--often the case in the lobby and lower floors of hospitals—which can cause concen-
trations of tension in changes of level. The so-called “soft floor,” an unfavorable feature in seismic zones,
can be present owing to significant changes in rigidity due to variations in height. The evaluator should
be aware that an in-fill wall can convert a column designed for support along its entire height into a
“short” column. Short columns have been the cause of collapse in buildings that were supposedly resis-
tant to seismic forces. The evaluator should take note of high concentrations of mass on upper floors of
a hospital, owing to the placement of heavy items like machinery, equipment, and water tanks on upper
floors. These can increase inertial forces and cause excessive displacement. Besides irregularities in plan,
variation of the type as well as mass and rigidity of materials can alter the resistance to loads that affect
the building. The evaluator should also determine whether elements (such as columns and walls) are
symmetrically distributed in height, to the edges, providing rotational rigidity.
Safety ratings for item No. 12 are: Low = Height of storeys differs by more than 20% and there are
significant discontinuous or irregular elements; Average = Stories have similar heights (they differ by less than
20% but more than 5%) and there are few discontinuous or irregular elements; High = Stories of similar
height (they differ by less than 5%); there are no discontinuous or irregular elements.

13. Structural resilience to various phenomena (meteorological, geological, among

others)
For this item, evaluators will refer to hazards present at the site of the hospital, found in the first
module, “Elements relating to the geographic location of the health facility.” Expertise is needed to
determine whether the hospital facility as a whole can function adequately given its geographic location

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and the natural forces that can affect it. The evaluator will look at variables both independently and
in their entirety to estimate structural behavior in response to different hazards or dangers other than
earthquakes. For example, a building’s design might be adequate to resist seismic forces but it could
be very vulnerable to hurricanes, and vice versa. For this item, evaluators will give greater weight to
the qualitative part of the safety index, that is, the level of exposure to each hazard. This will satisfy the
answer as to whether the facility’s structural design is adequate to resist natural forces.
Safety ratings for No. 13 are: Low = Low structural resilience to natural hazards present at the site of
the hospital; Average = Satisfactory structural resilience; High = Excellent structural resilience.

III. Elements related to non-structural safety

Aspects related to the second of the three modules are now assessed quantitatively in the calcula-
tion of the Hospital Safety Index: non-structural safety.
Elements that do not form part of the load-bearing system of the hospital facility are considered as
non-structural. These include critical systems such as electrical, water supply and sanitary networks and
heating, ventilation, air-conditioning systems etc; the furniture and office equipment, whether fixed or
mobile, as well as medical and laboratory equipment, supplies used for analysis and treatment as well
as architectural components of the building, and so forth.
There are five sub-modules, as follows:
1. Critical systems (including electrical, telecommunications, water supply, fuels, and medical
gases).
2. Heating, ventilation, and air conditioning systems in critical areas.
3. Fixed and mobile furnishings and equipment (including computers, printers, etc.)
4. Medical and laboratory equipment and supplies used for diagnosis and treatment.
5. Architectural components of the building.

3.1 Critical systems

This first sub-module is number 3.1 and is divided into five sub-groups: 3.1.1; 3.1.2; 3.1.3; 3.1.4
and 3.1.5; this covers items 14 to 44 in the checklist.

3.1.1 Electrical system

Includes items 14 - 21 in the checklist.

14. Generator has capacity to meet 100% of demand

The evaluator will verify that the generator begins to operate within seconds of the hospital los-
ing power, covering power demands for the entire hospital. If it cannot meet 100% of demand for the
entire hospital, it should meet demands for the emergency department, intensive care unit, sterilization

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unit, and operating theatre, that is, areas of the hospital that are most critical to maintaining its services.
Evaluators should confirm that power plant operators have emergency preparedness training. The work
area should be checked to see that there are flashlights and basic communications equipment.
Safety ratings for item No. 14 are: Low = Generator can only be started manually or covers 0–30% of
demand; Average = Generator starts automatically in more than 10 seconds or covers 31%–70% of demand;
High = Generator starts automatically in less than 10 seconds and covers 71%–100% of demand.

15. Regular tests of generator performance are carried out in critical areas
The evaluators will determine how frequently generator performance tests with satisfactory results
are carried out. This allows potential failures in the system to be anticipated, and provides measures to
be taken should a failure occur. The evaluators can also determine how issues about generator function
and repairs are communicated to the unit responsible for maintenance.
Safety ratings for item No. 15 are: Low = Tested every 3 months or more; Average = Tested every 1 to
3 months; High = Tested at least monthly.

16. Generator protected from damage due to natural phenomena

Evaluators will determine whether or not the generator is for use out of doors, and based on this,
its location. For outdoor generators, evaluators will inspect the casing and any form of protective cover-
ing. Depending on its location, the potential for flood damage should be evaluated. Its vulnerability
to strong winds or proximity to adjacent structures that might fall and cause damage due to wind or
seismic forces should also be evaluated. Drainage at the generator’s location should be evaluated: how
runoff is managed if the equipment is outside, and if placed indoors, whether there are floor drains or
openings.
It should be ascertained that the generator is well anchored and braced, without the possibility
of falling or shifting. This involves inspection of supports for the generator in the ground or flooring
and the condition and type of connections (checking for corrosion or other deterioration). If springs
are used to avoid vibration and noise, they must be well anchored since these devices amplify seismic
waves. The connections for fuel lines and electric cables must be flexible to avoid breakage should the
generator shift or fall. The lower that these heavy pieces of equipment are placed in the structure, the
less the chance that they will turn over, but they can still slide.
There should be easy and safe access to the equipment. The possibility that doors or other exits
would be blocked by cables or fuel lines should be considered if the equipment shifts or falls.
Evaluators should check the availability and storage of fuel, confirming that supplemental tanks
are always full and are located so that fuel can reach the generator by gravity rather than depend on
pumping at the moment of an emergency. Evaluators will inspect the physical condition of the fuel
tanks and electrical and hose connections. The condition of the batteries and replacement batteries
for the starter should be also inspected, to ensure that they cannot be damaged. Check for protection
against electrical discharge caused by atmospheric changes, etc.
Safety ratings for item No. 16 are: Low = No; Average = Partially; High = Yes.

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17. Safety of electrical equipment, cables, and cable ducts

The condition of the electrical networks throughout the hospital should be checked. They should be
completely anchored and protected from strong winds or flooding and channeled through electric cable
racks or conduits that protect them from twisting, breaking, or general deterioration. When cables travel
along roofs that empty through drain pipes or gargoyles, they should be positioned above the overflow
level. When the building has a basement or other areas that are likely to flood, evaluators will inspect the
location of sockets and whether they need to be raised.
An important element is the separation of electrical networks from other systems that they could
affect as water supply or sewage systems. If they are in close proximity to protective systems for electrical
atmospheric discharge, metal shielding should be considered.
Evaluators should inspect the position of outside power lines in relation to features on the hospital
grounds. Electric poles should not be located on hospital grounds, but if they are, evaluators should ensure
that transformers are well anchored. The possibility that poles could fall because of soil liquefaction or
wind should be considered. Tree branches can break or interfere with above-ground power lines; likewise,
tree roots can interfere with buried lines.
Safety ratings for item No. 17 are: Low = No; Average = Partially; High = Yes.

18. Redundant system for local electric power supply

The failure of local power supplies can cause a “domino” effect in the health facility, that is, successive
outages can occur. The evaluator should confirm that there is redundancy in the power supply, without
counting on the hospital’s own emergency generating system. There should be more than one entrance
to the facility from the local power supply, which should be from another circuit, clearly located in other
places and independent from the internal emergency system.
Safety ratings for item No. 18 are: Low = No; Average = Partially; High = Yes.

19. Protection for control panel, overload breaker switch, and cables
The evaluator will check the accessibility as well as condition and operation of the general distribu-
tion board, as well as control panels distributed throughout the facility. The location should be checked
to ensure that access cannot be blocked, that doors and windows are intact, and that there is sufficient
drainage to avoid flooding from a sudden gush of water.
The performance of the distribution board must be checked, including the capacity of the breaker,
its connections to the system, and the supports or anchors used for all of the panels and corresponding
equipment. Panels should be labeled indicating which control devices serve circuits in different areas.
Evaluators should verify the qualifications of the person responsible for operating the system, as well as
how he/she has been trained to communicate in an emergency.
Connections to the emergency back-up system, emergency lighting, and interior alarm systems
must be inspected. If these connections are located close to the emergency generator, all cables should
be appropriately channeled and in good condition.
Safety ratings for item No. 19 are: Low = No; Average = Partially; High = Yes.

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20. Lighting system for critical areas of the hospital

Evaluators will review lighting in critical areas of the hospital, including the emergency unit, inten-
sive care unit, operating theatre, laboratories, etc. They will test levels of lighting in rooms, the function
of lighting fixtures, and determine the safety of their bracing or supports. Some lights are suspended from
ceilings, others are attached to the structure. In the case of lighting used in surgery or obstetrics, manufac-
turers’ installation instructions generally suggest that they be bolted to beams. The evaluator should ensure
that lighting fixtures are not supported by false ceilings, especially where there are seismic hazards. Where
water filtration occurs on upper floors, leaks could cause short circuits in light fixtures. Evaluators should
confirm that lighting is connected to the emergency power system.
Safety ratings for item No. 20 are: Low = No; Average = Partially; High = Yes.

21. External electrical systems installed on hospital grounds

Evaluators will determine whether external substations or transformers are on hospital grounds
and their power capacity. These systems should be completely enclosed and there should be signs
clearly indicating that they are a power source. They should be isolated from fuel tanks. Anchors or
supports should be sufficient to prevent them from tipping over or sliding. Evaluators should take
into account the possibility of oil leaks in the case of a transformer and breaks in electrical cables.
Transformers or substations should not be placed close to trees because branches can break or inter-
fere with above-ground power lines; likewise, tree roots can interfere with buried lines. They should
be protected from electrical atmospheric discharge.
Safety ratings for item No. 21 are: Low = No electrical substations installed on hospital’s grounds;
Average = Substations installed but do not provide enough power to hospital; High = Electrical substations
installed and provide enough power to the hospital.

3.1.2 Telecommunications system

Includes items 22 - 28 in the checklist.

22. Condition of antennas and antenna bracing

Evaluators will verify the condition of antennas, their bracings and supports. Antennas and light-
ning rods are exposed and attached to the highest part of the structure, and therefore vulnerable to
strong winds. There should be at least three tie-downs, spaced 120 degrees apart; four tie-downs should
be spaced 90 degrees apart. Grounding devices for lightning rods should be correctly installed and not
be used to anchor other systems.
Safety ratings for item No. 22 are: Low = Poor or does not exist; Average = Satisfactory; High =
Good.

23. Condition of low-voltage systems (Internet and telephone connections/cables)

Verify that cables are properly connected in strategic areas to avoid system overload. Cables for com-
puter and telephone networks should be protected from events such as high winds and flooding, so that

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the systems can function in adverse conditions. The main components of low current systems, such as
servers and network hubs should be in protected areas that are free of items that could potentially block
access.
To connect the telephone exchange to each of the extensions or telephones in a building, there is a
system of wires that must run separately from electrical wires, to avoid overloading the system. Likewise,
internal communications wires must be isolated. The wires should be protected in polyethylene tubes;
plastic electrical boxes should house the outlets and be placed at least half a meter above the floor.
Safety ratings for item No. 23 are: Low = Poor or does not exist; Average = Satisfactory; High =
Good.

24. Condition of alternative communications systems

The evaluator will check the condition of the hospital’s alternative communications systems, in-
cluding two-way mobile radios, satellite telephone, Internet, and loudspeakers, in order to maintain
internal as well as external contact in the event of a disaster. Components of internal networks should
be reviewed to ensure that vulnerability at different points in the system has been eliminated. It is
important to keep in mind that internal communications are dependent on the operation of the emer-
gency power generation system in case of a disaster.
Safety ratings for item No. 24 are: Low = Poor or does not exist; Average = Satisfactory; High =
Good.

25. Condition of anchors and braces for telecommunications equipment and

cables
The evaluators should confirm that telecommunications equipment is anchored. Telephone ex-
change consoles, computers, and servers should have anchors to prevent tipping or sliding. There should
be adequate conduit tubing for cables to prevent them from deteriorating.

IF THE SYSTEM DOES NOT NEED ANCHORS OR BRACING,

LEAVE BOXES BLANK.

Safety ratings for item No. 25 are: Low = Poor; Average = Satisfactory; High = Good.

26. Condition of external telecommunications systems installed on hospital

grounds
The evaluators will verify that exterior telecommunications systems do not interfere with hospital
communications.
Safety ratings for item No. 26 are: Low = External telecommunications systems cause major interfer-
ence with hospital communications; Average = External telecommunications systems cause moderate interfer-
ence with hospital communications; High = External communications cause no interference with hospital
communications.

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27. Site has adequate conditions for telecommunications systems

Evaluators should check the condition of the sites for the telephone exchange and computer network
server. Depending on the type and size of the exchange, the space must accommodate switching equip-
ment, power supply, storage batteries, and climate control equipment; there must also be room for opera-
tors and maintenance workers. Battery storage areas should be ventilated separately.
Doors and windows should close tightly to keep out wind and water, and doors should have mod-
erate fire proofing. There should be adequate lighting for personnel to work, but the equipment should
be protected from direct sunlight. It is preferable to place equipment against one wall. To avoid water
damage, water filtration apparatus, toilets, and bathrooms should not be on floors above the equipment.
Cables and wires should be encased in conduit tubing to prevent deterioration. All equipment should be
anchored according to its weight and dimensions. The evaluator should verify that installations are not
subject to explosion, in case of sparks.
Safety ratings for item No. 27 are: Low = Poor or does not exist; Average = Satisfactory; High = Good.

28. Safety of internal communications systems

Verify the condition of loudspeakers, public address systems, speaker systems, intercoms and oth-
ers, that serve to communicate with the personnel, patients, and visits in the hospital. Confirm also
the existence of audible systems as bells, horns used to disseminate alarms, alerts or evacuation. The
existence of redundant and alternate systems for internal communication guarantee that personnel,
patients and visits are timely and clearly contacted in emergencies and disaster. The evaluators should
request that the internal communications systems are tested and confirm that the message was well
received.
Safety ratings for item No. 28 are: Low = Poor or does not exist; Average = Satisfactory; High =
Good.

3.1.3 Water supply system

Includes items 29-33 in the checklist.

29. Water tank has permanent reserve that is sufficient to provide at least 300
liters daily, per bed, for 72 hours
Evaluators will verify that water storage is sufficient to satisfy user demand for three days. Typi-
cally, water storage for hospitals is in cisterns or reserve tanks on the ground floor and elevated tanks.
It is important to check locations in the hospital that are not served by the main water system, and
confirm their reserves are sufficient for three days. If wells exist on hospital grounds, the percentage of
supply they provide and whether they are used regularly or as reserves should be ascertained.
Safety ratings for item No. 29 are: Low = Sufficient for 24 hours or less; Average = Sufficient for more
than 24 hours but less than 72 hours; High = Guaranteed to cover at least 72 hours.

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30. Water storage tanks are protected and in secure locations

Evaluators will visit all water tanks, whether elevated on towers or on the building, or inside,
in the case of pressurized or hydro-pneumatic systems. Cisterns should not be located in areas sus-
ceptible to flooding because of the risk of contamination nor should they be in areas with landslide
hazards. They should have manhole covers to prevent access to non-authorized personnel and items
from falling inside. The tanks should not show cracking or vegetation growth. It is important to
determine whether the failure of a water tank would flood critical areas of the hospital, and there
should be overflow and drainage areas for such a contingency.
Elevated tanks should meet these same criteria in addition to being supported above structural
roof elements. Special attention should be given to how plastic tanks are supported and anchored. In
high winds they can tip over if they are empty, which will affect the attached pipes. Air valves extend
above the level of the tank cover and should be braced to avoid movement or breakage in high winds.
Any hydraulic network components on the roof should be anchored.
Safety ratings for item No. 30 are: Low = The site is susceptible to structural or non-structural failure;
Average = Failure would not cause collapse of tank; High = Low possibility of functional failure.

31. Alternative water supply to major distribution network

The agencies or mechanisms necessary to supply the hospital with water, in case the public system
fails, should be identified.
There should be redundancy in all critical or lifeline systems, and it is advisable for the facility’s
main cistern to be supplied by the local service in at least two places that can maintain the necessary
reserve capacity. Another option is to use private wells to supply the facility; their availability should be
confirmed. The evaluator should identify the entity responsible for restoring local water supply should
it fail, and check access from tanker trucks to water storage tanks.
Safety ratings for item No. 31 are: Low = Provides less than 30% of demand; Average = Provides 30%
to 80% of demand; High = Provides more than 80% of daily demand.

32. Condition of water distribution system

Evaluators will check the condition and proper performance of all aspects of the water distribution
system including storage tanks, valves, pipes, and connections. The components connecting local water
service to the cisterns are a critical part of the network. The cistern float valve controls the amount of
water that enters the tank and shuts off flow when the cistern is full. If the valve is not in proper working
order water will be wasted without filling the cistern, and the runoff can erode structural supports.
It is important that evaluators check the general condition of the hospital distribution network to
ensure that water reaches the necessary service points. Leaking pipes can cause damage in any of the ar-
eas where they are located: along suspended ceilings, behind walls, and underground. Pipe connections
are vulnerable and should be checked for signs of deterioration. It is important to check that flexible
connections are used, for example, between exterior tanks and points where pipes enter the building
and between pumps and impulsion pipes. Flexible connections should be used where components are

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in contact with structural elements, and should be firmly anchored so that the structure and water pipes
move together in the case of seismic shaking.
Safety ratings for item No. 32 are: Low = Less than 60% are in good operational condition; Average =
Between 60% and 80% are in good condition; High = Above 80% are in good condition.

33. Supplementary pumping system

As mentioned elsewhere, critical systems should be redundant, beginning with systems inside the
hospital. Evaluators should identify the existence and performance of the supplementary or back-up
pumping system. At least two pumps should be in place (to ensure that if one pump fails, there is a
back-up) to move water between reserve and compensation tanks if the main system fails in an emer-
gency. The pumps should both be able to meet the minimum demand for water needs of the hospital.
The same requirements hold for water distribution in the facility that is independent from the main
pumping system.
Safety ratings for item No. 33 are: Low = There is no back-up pump and operational capacity does
not meet daily demand; Average = All pumps are in satisfactory condition; High = All pumps and back-up
systems are operational.

3.1.4 Fuel storage (gas, gasoline, diesel)

Includes items 34-37 in the checklist.

34. Fuel tanks have at least 5-day capacity

Fuel tanks should be located in a safe place and properly secured. The fuel used for the generator
may not be the same used for hospital boilers and other services, so it is important that all fuel tanks
be very clearly labeled, and where possible, stored in different areas. The evaluators should check the
size of reserve tanks, check that the reserve is sufficient to meet the demand for each type of fuel, and
determine how often fuels are delivered.
Safety ratings for item No. 34 are: Low = Fuel storage is not secured and has less than 3-day fuel capac-
ity; Average =Fuel storage has some security and has 3- to 5-day fuel capacity; High = Fuel storage is secure
and has capacity for 5 or more days.

35. Fuel tanks and/or cylinders are anchored and in a secure location
Because of the weight of fuel tanks, it is important that they are well anchored to prevent them
from tipping in the case of seismic events. The evaluators should determine whether anchors are metal
and whether they are in good condition. Where tanks are supported by concrete or brick walls, the walls
should be checked for cracks and the braces or anchors checked for signs of sinking. Large horizontal
tanks can slide and break connection hoses, so in seismic areas they should be supported with clamps.
It is important to keep in mind that the heavier the tank and the higher the center of gravity, the
greater the likelihood that it will tip over. Cylinders positioned vertically should be tied down in at least
three directions. This item is closely related to item No. 36, and can be evaluated at the same time.

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Safety ratings for item No. 35 are: Low = There are no anchors and the tank enclosure is unsafe; Aver-
age = Anchors are inadequate; High = Anchors are in good condition and the tank enclosure is adequate.

36. Safe location of fuel storage

Evaluators should verify that the tanks containing flammable liquids are at a safe distance from
the hospital and its electrical plant, boilers, kitchens, and other areas that could pose a fire risk. Where
tanks are in enclosed areas they should have adequate supports and the enclosure should be built of
non-combustible materials. These areas should be well-marked and well-illuminated, behind fencing,
kept under surveillance, and, where possible, have a security alarm, but at the same time be easily ac-
cessible for authorized personnel. Fuel tank storage areas should have good drainage and be in locations
that are not prone to flooding, landslides, or soil liquefaction. In the case of strong winds, they should
be protected from flying objects. Fuel storage should be sheltered from construction and any other ac-
tivities that could potentially damage them. In addition to reviewing the site, evaluators should check
fire protection equipment associated with the fuel storage.
Safety ratings for item No. 36 are: Low = There is risk of failure and that tanks are not accessible;
Average = One of the two conditions has been met; High = The fuel storage tanks are accessible and they are
located in a secure site.

37. Safety of the fuel distribution system (valves, hoses, and connections)
Fuel leakages are extremely dangerous and it is important to control them carefully. This implies
correct performance of all valves, hoses, and connections. The evaluators should ensure that connec-
tions are flexible where attached to equipment and where they cross structural elements. However,
when connections are joined to structural elements they should be rigid, assuming there is no possibil-
ity of settling.
Safety ratings for item No. 37 are: Low = Less than 60% of system is in good operational condition;
Average = between 60% and 80% of system is in good operational condition; High = More than 80% of
system is in good operational condition.

3.1.5 Medical gases (oxygen, nitrogen, etc.)

Includes items 38-44 in the checklist.

38. Sufficient medical gas storage for minimum of 15-day supply

The evaluators will check the reserve capacity for each type of medical gas used in the hospital
between the central supply bank and the cylinders or bottles in areas of service. It is also important to
confirm the frequency of deliveries of gases.
Safety ratings for item No. 38 are: Low = Less than 10-day supply; Average = Supply for between 10
and 15 days; High = Supply for at least 15 days.

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39. Anchors for medical gas tanks, cylinders, and related equipment
Gas tanks and cylinders are located in the service areas where they are used. They contain a variety
of gases; some are toxic, others are flammable. They must be well anchored because their valves are easily
damaged if they fall, and to avoid injuring patients or staff or damaging other elements. Vertical oxygen
tanks should be anchored in three or four directions with welded connections or bolts. Evaluators should
ensure that anchoring is adequate and the materials are in good condition. Narrow vertical oxygen tanks
should be secured with three, evenly spaced tie-downs in case of high winds or seismic activity. Horizontal
tanks should be anchored to walls so they cannot slide as a result of shaking during seismic events. See
also item No. 35.
Safety ratings for item No. 39 are: Low = Anchors are lacking; Average = Quality of anchors is inad-
equate; High = Anchors are of good quality.

40. Availability of alternative sources of medical gases

Evaluators should verify that alternative sources for medical gases have an oxygen supply bank
with the necessary reserve and have reserve bottles available. It should also be confirmed whether the
supplier of medical gases is in the vicinity and has reserves available.
Safety ratings for item No. 40 are: Low = Alternative sources are lacking or are below standard; Aver-
age = Alternative sources exist and are in satisfactory condition; High = Alternative sources exist and are in
good condition.

41. Appropriate locations for storage of medical gases

Oxygen supply banks as well as storage tanks should be located outside of the hospital building
because of the risk of tank explosion. The site should be easily accessible, in an area unlikely to flood, at
a distance from any heat sources, and protected from flying or falling objects.
Safety ratings for item No. 41 are: Low = Storage is not accessible; Average = Storage is accessible but
hazards exist; High = Storage is accessible and there are no hazards.

42. Safety of medical gas distribution system (valves, pipes, connections)

Storage devices and distribution networks use color coding to identify different types of medical
gases. In addition to different colors, the bottles or cylinders for each type of gas use different valves,
eliminating the hazard of connecting the wrong type of gas. Notwithstanding these precautions, the
evaluator should check the color coding.
The major danger if gas tanks fall is that the valves will break and there will be an uncontrolled
flow of gases, with dangerous consequences. It is important to inspect the valves and ensure that cou-
plings are flexible and there is enough play to tolerate small movement, but that tanks cannot fall or
knock against each other while they are connected to the supply bank. Tubing should be protected
and correctly anchored to structural elements. Flexible couplings should be used where tubing crosses
structural joints. It is important to examine the network for leaks.

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Safety ratings for item No. 42 are: Low = Less than 60% of system is in good working condition; Aver-
age = Between 60% and 80% of system is in good working condition; High = More than 80% of system is
in good working condition.

43. Protection of medical gas tanks and/or cylinders and related equipment
Evaluators will verify that there is a site designated solely for tanks and/or cylinders and related
equipment for medical gases and that only this equipment occupies the designated area. As outlined in
item No. 41, it is advisable that the site be at a distance from the hospital buildings, that there be fenc-
ing around the site, and signage indicating that the equipment is dangerous. Evaluators will ascertain
that the personnel responsible for managing medical gases know all safety procedures for each type of
gas being used.
Safety ratings for item No. 43 are: Low = No areas are used exclusively for this equipment and there
are no qualified personnel to operate it; Average = Areas are used exclusively for this equipment but personnel
are not trained to operate it; High = There are areas used exclusively for this equipment and it is operated by
qualified personnel.

44. Adequate safety in storage areas

The evaluator will verify that tanks, storage areas, oxygen supply banks, etc., are used exclusively
for medical gases. The sites should be easily accessible and free from potential obstructions. Their size
must be adequate for the correct handling of bottles or tanks from the delivery point, to storage, and
to the area where they are put to use. Fire extinguishing equipment must be available, and personnel
trained in using it.
Safety ratings for item No. 44 are: Low = No areas are reserved for storage of medical gases; Average
= Areas are reserved for storage of medical gases but safety measures are inadequate; High = There are areas
reserved for storage of medical gases and the site does not present risks.

3.2 Heating, ventilation, and air-conditioning (HVAC) systems in critical areas

This is the second sub-module of the non-structural module which addresses aspects which should
be taken into account whilst checking heating, ventilation and air-conditioning systems in the critical
areas of the hospital. This covers items 45-51 in the checklist.

45. Adequate supports for ducts and review of flexibility of ducts and piping that
cross expansion joints
All HVAC ductwork and pipes must be supported adequately by the building structure, without the
possibility of horizontal movement, especially in seismic areas. The bracing should be rigid and with ad-
equate slope to allow ductwork to move in three directions. Ductwork that crosses roofs should be anchored
so that wind suction will not affect it, and be placed above the level of the roof’s spillway. Evaluators should
check the distance between supports to ensure that there are no deflections caused by the weight of the ducts,
which could cause them to fall. Where ductwork is hidden by false ceilings, ceiling tiles should be removed

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to check the ducts. Supports for ductwork that crosses between blocks of buildings should be inspected to
ensure that they will not fall and/or damage elements around the ducts.
Safety ratings for item No. 45 are: Low= Supports are lacking and connections are rigid; Average = Sup-
ports are present or connections are flexible; High = Supports are present and connections are flexible.

46. Condition of pipes, connections, and valves

Pipes should travel through conduits so that they are protected from humidity. Evaluators will
check how valves operate and will review the condition of pipes at key points to ensure they are pro-
tected in kitchens, boilers, or any areas where there is steam and the coatings or isolation of piping
could be affected. Evaluators should check that condensation will not affect isolation of piping and that
leaks from upper floors will not affect components. Humidity can ruin false ceilings and other elements
or equipment that come in contact with the piping.
Piping should have flexible connections where it crosses expansion joints of the building. In cases
where the pipes carry hot water or steam, evaluators should confirm that expansion connections are
used, as well as safety valves for the system. The pipes should be completely supported and at a distance
from electrical panels or wiring. Safety valves or air valves for steam, hot, or room temperature water
respond to seismic amplifications like inverted pendulums, so they should have lateral supports.
Safety ratings for item No. 46 are: Low= Poor; Average = Satisfactory; High = Good.

47. Condition of anchors for heating and/or hot water equipment

Generally, boilers or water heaters produce hot water or steam. They are vulnerable and can pose major
risks. Their weight puts them at the mercy of inertial forces in an earthquake. They can tip over due to seismic
shaking, which can break the water pipes, causing flooding. The water supply for the fire extinguishing sys-
tem can be put at risk when water connections are broken. Fire danger increases if cables or gas hoses are cut,
or liquid fuel spills. To avoid these hazards, evaluators should confirm that the boiler is completely anchored
to the foundation. Individual hot water heaters should be connected at the top and bottom to a solid wall.
If one anchor detaches, it is unlikely that the water heater will slide. Solar heaters are usually located on roofs
and are vulnerable to strong winds as well as seismic forces. Evaluators should confirm that these elements
are well fastened to the roofing.
Safety ratings for item No. 47 are: Low = Poor; Average = Satisfactory; High = Good.

48. Condition of anchors for air-conditioning equipment

Air conditioning units can be local or central, compact or not. Central air conditioning units
can either be compact or split with a fan coil unit. They are very heavy and are generally located in
areas with ventilation, such as on roofs, upper floors of the hospital, or floors dedicated to building
machinery and equipment. Because of their weight, they can significantly change the behavior of the
structure. Unless they are well anchored, they can move or overturn, and as a result can cause partial or
total collapse of the building. The explanation in item No. 47 about heavy heating equipment is valid
for air conditioning units as well. Smaller units are located in the areas that they serve and are window
or portable units.

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Smaller split systems have the evaporator inside and the compressor and condenser outside, on the
roof, patio, or elsewhere. The outside equipment is vulnerable to strong winds and floods and must be
well anchored and located out of reach of water that would damage the electrical system. Indoor units
should be firmly anchored to structural elements; if they should fall they could injure people or damage
other equipment.
Safety ratings for item No. 48 are: Low = Poor; Average = Satisfactory; High = Good.

49. Location of enclosures for HVAC equipment

Enclosures for boilers should be away from the hospital building. Preferably, they should be
housed in installations with some roof cover, isolated from fuel storage, in areas that are easy to access,
and difficult to obstruct or flood. When central air conditioning units are on the roof of buildings they
should be protected from the weather. Any HVAC equipment should be easy to access, protected from
elements that might obstruct access, and in areas that are protected from flooding.
Safety ratings for item No. 49 are: Low = Poor; Average = Satisfactory; High = Good.

50. Safety of enclosures for HVAC equipment

Evaluators should confirm that enclosures for HVAC equipment are always accessible and large
enough to allow the operators to work comfortably on the equipment. Extractors for steam should
ventilate the boiler room. Evaluators will confirm that lighting is adequate to see the controls, and that
there is adequate drainage for runoff of water, grease, or fuel. The control panel should be steam-proof
and protected from the temperature of the boiler. The enclosure should be equipped with fire extin-
guishing equipment and emergency lighting. The sanitary water disposal network, if this is found inside
the enclosure, should be connected separately from the rain water disposal network, avoiding the entry
of water during heavy rains as a result of sanitary devices at a lower level.
Safety ratings for item No. 50 are: Low = Poor; Average = Satisfactory; High = Good.

51. Operating condition of HVAC equipment (boiler, air-conditioning systems,

exhaust, etc.)
Key areas of the hospital are dependent on the proper operation of HVAC equipment. These areas
include the kitchen, sterilization center, refrigerators, medicine storage, laundry, operating rooms, and in-
tensive care unit. Under normal conditions equipment failure can wreak havoc; when an unexpected event
occurs, failure can result in disaster.
Because they are critical elements, HVAC equipment should be redundant. The hospital should have at
least two boilers, so that if one is undergoing maintenance or fails, the other will function. Untreated water
used in boilers can cause deterioration, so there should be a water softener in the area. The most common
failures in this equipment occur because of the controls. Overheating occurs because of low water level,
and variation in the pressure of the boiler causes inefficient operation. If overheating or pressure variations
coincide with failure of a safety valve there can be an explosion. Deposits of scale will be evident if the water
softener is not adequate; these deposits lessen efficiency and corrode the metal.

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The evaluator should make a basic inspection of the condition of the controls, the exterior appearance
of the boiler, review laboratory analysis of the water, and check operation of the equipment alarm. The level
of training of the operator is important. Evaluators should ask if the operator has a copy of the operation
and maintenance manual (for daily cleaning) and how often preventive maintenance is done by specialists.
They should see that extractors function correctly to eliminate steam from boiler rooms, from the kitchen,
and from operating rooms. Controls and alarms on the central air conditioning equipment should also be
checked. Portable systems can be used in an emergency in key areas.
Safety ratings for item No. 51 are: Low = Poor; Average = Satisfactory; High = Good.

3.3 Office and storeroom furnishings and equipment (fixed and movable) includ-
ing computers, printers, etc.
This is the third sub-module of the non-structural module. Here the aspects related to furnishings,
to office equipment and the security of store-rooms are considered, including both fixed and mobile
components. It includes items 52-54 on the checklist.

52. Anchors for shelving and safety of shelf contents

Evaluators should check that shelving is fixed to walls and/or has safety supports and that they have a
lip or railing to keep contents from falling. Offices, libraries, and clinical records archives commonly have
shelving units with glass doors. The units should be connected to each other and unbreakable material
should replace the glass. Where there are rows of high, free-standing shelves, they must be anchored to the
floor, connected to each other at the top by ties that cross the room and attached to the wall at either end
of the row of shelves. Connecting the shelves increases lateral stability, lessening the chance that they will
fall. For tall shelving made of combustible material, the condition of lighting fixtures and wiring near the
shelves should be inspected. The evaluator should check areas where falling shelves would obstruct exits.
Depending on the type of material in the office or storeroom, there should be fire extinguishing equip-
ment near the exits, and personnel should know how to operate it.
Safety ratings for item No. 52 are: Low = Shelving is not attached to walls; Average = Shelving is at-
tached but contents are not secured; High = Shelving is attached and contents are secured.

53. Safety of computers and printers

In the information technology age, much of a hospital’s information is found on its computers. To
ensure that a facility continues to function, computers and their contents must be secured against dam-
age caused by natural phenomena. The evaluators will confirm that computers, printers, and servers are
secured to tables or that there is a lip or railing that will prevent equipment from sliding off the table. If
tables are on wheels, the wheels should be in the locked position. Where there is raised access flooring that
allows computer wiring to run under the floor, the evaluators should check anchors to the structural slab
and vertical and horizontal bracing.
Safety ratings for item No. 53 are: Low = Poor; Average = Satisfactory; High = Good or does not require
anchor.

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54. Condition of office furnishings and other equipment

Evaluators should check office furnishings and other equipment following the criteria outlined for
items 52 and 53, and adapt these criteria to the hospital being evaluated. Articles hung on walls and
above desks (clocks, pictures, televisions, etc.) must be completely anchored and not hang directly above
a work station or door. Particularly in seismic zones, filing cabinets on wheels should have chocks or be
attached to walls to keep them from sliding; filing drawers should have latches to keep them from sliding
open. Evaluators should consider potential damage caused by strong winds: these forces can break large
windows, damaging the furnishings and contents of offices and other rooms.
Safety ratings for item No. 54 are: Low = Poor; Average = Satisfactory; High = Good or does not require
anchor.

3.4 Medical and laboratory equipment and supplies used for diagnosis and
treatment
This is the fourth sub-module on non-structural elements and includes safety of medical and labo-
ratory equipment, emphasizing critical hospital services. It includes items 55-66 on the checklist.

55. Medical equipment in operating theaters and recovery rooms

The evaluators will first determine whether equipment is functional, and then check safety fastenings
and anchors. Ceiling light fixtures in surgery should function, the hinges on the extension arm should be
properly adjusted, and fixtures should be well anchored to beams to prevent them from swinging. The oper-
ating table should be completely immobilized. Anaesthesia equipment, electrosurgical units, monitors, and
instruments should be attached to rolling carts, which in turn should be secured to the operating table when
in use. Braces, latches, and caster brakes on all equipment should be inspected.
Life support equipment should be completely anchored, eliminating the possibility of disconnection
from the patient. Flexible hoses and tubes with swivel connectors and automatic shut-off valves should be
used for connecting equipment to medical gases, water, or steam. Cables that connect equipment to a power
source should pass through a conduit so that it cannot tangle during rotational motion. Equipment should
not be placed above the patient. When not in use, equipment should be braced against a wall, with brakes
applied to carts and rolling tables.
Safety ratings for item No. 55 are: Low = The equipment is in poor condition or it is not secured; Aver-
age = The equipment is in fair condition or not properly secured; High = Equipment is in good condition and is
secured.

56. Condition and safety of radiology and imaging equipment

The condition of X-ray equipment and carts holding the equipment should be checked; brakes for
cart wheels must be functional. Where computed axial tomography (CAT) scanners are used, evalua-
tors should verify that they function, and ensure that they are located where flooding cannot damage
them. Operators should be familiar with all safety protocols for using the equipment. Criteria used in
item 55 can be applied to equipment that should be anchored.

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Because this equipment is heavy and vulnerable to horizontal seismic forces, adequate anchors
are needed to keep them from tipping or moving. The higher the center of gravity of these items, the
greater the possibility they will tip over. Power and other connections should be flexible: it is better
for cables to be disconnected than to break. Hospital equipment is highly sensitive to sudden changes
in voltage (e.g., computed tomography scanner, mammography equipment, excimer laser, magnetic
resonance imaging scanner) so evaluators should ensure that they have voltage regulators and earth
grounding to protect equipment from electrical discharge.
Safety ratings for item No. 56 are: Low = The equipment is in poor condition or it is not secured; Av-
erage = The equipment is in fair condition or not properly secured; High = Equipment is in good condition
and is secured.

57. Condition and safety of laboratory equipment

The criteria for items 52 to 56 can be adapted when evaluating the condition and safety of labora-
tory equipment. When inspecting the laboratory, evaluators should pay special attention to handling
and securing toxic samples. If containers break or leak during a disaster, technicians, patients, or the
laboratory itself could be contaminated.
Safety ratings for item No. 57 are: Low = The equipment is in poor condition or it is not secured; Av-
erage = The equipment is in fair condition or not properly secured; High = Equipment is in good condition
and is secured.

58. Condition and safety of medical equipment in emergency services unit

Criteria in items 52-57 are valid when adapted to equipment in the emergency services unit.
Evaluators should check that this equipment, which includes crash carts, oxygen tanks, monitors, etc.,
is in working order and is secured.
Safety ratings for item No. 58 are: Low = The equipment is in poor condition or it is not secured; Av-
erage = The equipment is in fair condition or not properly secured; High = Equipment is in good condition
and is secured.

59. Condition and safety of medical equipment in intensive or intermediate care

unit
Most criteria in items 52-58 are valid when adapted to equipment in the intensive care unit. Evalu-
ators should check that basic and specialized intensive care equipment is in good working order and well
secured. This equipment includes life support systems, ventilators, resuscitation equipment, oxygen tanks,
monitors, etc. The most rigorous inspection should be carried out in quarantine units of the hospital be-
cause of the added hazards of contamination or infection.
Safety ratings for item No. 59 are: Low = The equipment is in poor condition or it is not secured; Av-
erage = The equipment is in fair condition or not properly secured; High = Equipment is in good condition
and is secured.

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60. Condition and safety of equipment and furnishings in the pharmacy

Criteria in items 52-57 are valid when adapted to equipment in the pharmacy. Refrigeration units
for medicine should be inspected to ensure they are in good order and their contents secured. Shelving
used for storage of medicines must be well anchored (see item 52). Because some materials in the phar-
macy are flammable, there should be adequate fire protection items or systems (extinguishers, standpipe
systems, etc.) and pharmacy staff must be trained in operating this equipment.
Safety ratings for item No. 60 are: Low = The equipment is in poor condition or it is not secured; Av-
erage = The equipment is in fair condition or not properly secured; High = Equipment is in good condition
and is secured.

61. Condition and safety of equipment in the sterilization unit

Most criteria in items 52-57 and 60 are valid when adapted to equipment in the hospital’s ster-
ilization unit. Evaluators should check the condition of autoclaves, and review the operator’s training
in managing them in the case of emergency. Water leaks originating outside of the unit and possible
contamination of stored items is an issue in sterilization units, so evaluators should determine whether
there are water filtration systems on upper floors, water outlets, or, in the worst case, toilets that could
contaminate stored items. Proper labeling for routing sterile and contaminated equipment should be
checked. Evaluators must ensure that safety measures are being used for shelving and trolleys where
sterilized materials are stored (see item 52); materials can be contaminated if shelves or trolleys tip
over during a seismic event. Autoclaves are heavy and they should be completely anchored in seismic
zones. The evaluators must also ensure that fire protection items or systems are present (including ex-
tinguishers, standpipe systems, etc.) and that the staff is qualified to use it. The proximity of doors and
windows to the materials being sterilized should be checked, as well as the materials used for doors and
windows.
Safety ratings for item No. 61 are: Low = The equipment is in poor condition or it is not secured; Av-
erage = The equipment is in fair condition or not properly secured; High = Equipment is in good condition
and is secured.

62. Condition and safety of medical equipment for neonatal care

Criteria in items 52-59 are valid when adapted to equipment for neonatal care. Evaluators should
check that equipment is in working order and is secured. Specific neonatal equipment includes incuba-
tors, resuscitation equipment, oxygen tanks, monitors, etc. Sanitation and hygiene should be rigorously
reviewed in these units, particularly in birthing rooms, because of the vulnerable condition of new-
borns. Doors and windows should be able to resist strong winds; if water penetrates the area, special-
ized equipment can be damaged or destroyed. It is difficult to transfer newborns to other areas of the
hospital because of their vulnerability.
Safety ratings for item No. 62 are: Low = The equipment is lacking, is in poor condition, or is not
secured; Average = The equipment is in fair condition or not properly secured; High = Equipment is in good
condition and is secured.

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63. Condition and safety of medical equipment and supplies for burn management
Most criteria in items 52-59 are valid when adapted to equipment for burn management. Evalu-
ators should check that basic and specialized burn care equipment and supplies are in good working
order and well secured. This equipment includes life support systems, ventilators, oxygen tanks, moni-
tors, crash carts, etc.
Safety ratings for item No. 63 are: Low = The equipment is lacking, is in poor condition, or it is not
secured; Average = The equipment is in fair condition or not properly secured; High = Equipment is in good
condition and is secured.

64. Condition and safety of medical equipment for nuclear medicine and radiation
therapy
Criteria in items 52-57 and 60 are valid when adapted to nuclear medicine and radiation therapy.
Evaluators should check the handling, condition, and safety of samples. Supplies should be stored in areas
where they cannot fall or be hit by other objects. If containers break or leak during a disaster, technicians
and patients could be contaminated. Drums used for radioactive waste must have secure covers. It is im-
portant to verify that radiation sensors and chambers for handling samples function correctly, and that
signs indicate restricted areas. As in other areas of the hospital, fire extinguishing equipment should be
checked, and it should be verified that staff know how to handle it.

IF THE HOSPITAL DOES NOT HAVE THESE SERVICES,

LEAVE BOXES BLANK.

Safety ratings for item No. 64 are: Low = The equipment is lacking, is in poor condition, or it is not
secured; Average = The equipment is in fair condition or not properly secured; High = Equipment is in good
condition and is secured.

65. Condition and safety of medical equipment in other services

Many of the elements addressed in items 52-64 will be applicable in other services of the hospital
not already addressed. These could include cardiology, orthopedics, pediatrics, maternity, physiothera-
py, etc. The evaluators should carry out a review of the remaining areas, giving the most weight to areas
that would influence the overall function of the hospital.
Safety ratings for item No. 65 are: Low = More than 30% of equipment is at risk of material or func-
tional failure and/or equipment puts the entire service’s operation at direct or indirect risk; Average = Between
10% and 30% of equipment is at risk of loss; High = Less than 10% of equipment is at risk of loss.

66. Anchors for shelving and safety of medical contents

This item should be evaluated at the same time as item 52. Evaluators should verify that shelves
found in all critical areas which are considered in this fourth sub-module are attached to walls and/or

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have safety supports. Shelving units should be anchored together, especially in seismic zones. Shelves
should all have lips or railings to prevent bottles or other material from falling. Where there are rows
of high, free-standing shelves, they must be anchored to the floor, connected to each other at the top
by ties that cross the room and attached to the wall at either end of the row of shelves. Connecting
the shelves increases lateral stability, lessening the chance that they will fall. For tall shelving made of
combustible material, the condition of lighting fixtures and wiring near the shelves should be inspected.
Depending on the type of material in the area being evaluated, there should be fire extinguishing equip-
ment near the exits.
Safety ratings for item No. 66 are: Low = Shelves are anchored or shelf contents are secured in less than
20% of cases; Average = Shelves are anchored or shelf contents are secured in 20% to 80% of cases; High =
More than 80% of shelves are anchored and the contents of shelves are secured (or shelving and contents do
not require anchors).

3.5. Architectural elements

This fifth aspect to be evaluated in the non-structural module is covered by sub-module 3.5 and
it is composed of 18 items or lines in the checklist (includes items 67 to 84).

67. Condition and safety of doors and entrances

The evaluators should check the condition of doors and entrances to the hospital and their abil-
ity to resist wind, seismic, and other forces. They should be completely attached to the frames, and
the frames, in turn, must be firmly anchored to the surrounding walls or panels. Doors and entrances
should be free of obstacles and wide enough to allow rapid movement of patients and hospital staff in
emergency situations. Evaluators should pay special attention to doors and entrances to critical areas
such as the emergency services unit, intensive care unit, operating theatres, etc.
Safety ratings for item No. 67 are: Low = Subject to damage and damage to element(s) would impede
the performance of this and other components, systems, or operations; Average = Subject to damage but dam-
age to element(s) would not impede function; High = No or minor potential for damage that would impede
the performance of this and other components, systems, or operations.

68. Condition and safety of windows and shutters

As in the case of doors, outlined in item 67, windows should be able to resist hurricane force
winds, especially in critical areas of the hospital such as emergency services, operating theaters, intensive
care unit, sterilization unit, pharmacy, etc. Where possible, evaluators should check the thickness and
type of glass in the windows, since these two parameters, along with the area of glass exposed to wind,
define the resistance of glass windows. It is advisable to use windows with laminated glass or made of
polycarbonate in critical areas. Where wood windows are used, they should be checked for moisture
and termite damage. If windows are not secure, wind and rain can destroy or damage medical equip-
ment. Evaluators often underestimate the loss of hospital beds and impact on patients by not taking
into account rain and wind damage to rooms.

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Safety ratings for item No. 68 are: Low =Subject to damage and damage to element(s) would impede the per-
formance of this and other components, systems, or operations; Average = Subject to damage but damage to element(s)
would not impede function; High = No or minor potential for damage that would impede the performance of this and
other components, systems, or operations.

69. Condition and safety of other elements of the building envelope (outside walls,
facings, etc.)
Hospital facilities’ external building envelope can be of different materials, such as masonry, glass, wood
or aluminium and sometimes they are even of mixed materials. It is recommended that in seismic zones fac-
ings should not be veneered, but should be integrated into the wall. The evaluator should review the techni-
cal and construction status of the building envelope components. They should be reviewed to ensure that
they are not cracked, misshapen or loose. In relation to this last point, these walls should be appropriately
braced to the structural components, so that they resist seismic movements or strong hurricane wind forces,
amongst other considerations. The analysis should be much more rigorous in the critical areas. In the event
of building envelopes with fixed sections of glass or wood, the evaluator should apply the same restrictions as
in the case of shutters made of these materials.
Safety ratings for item No. 69 are: Low =Subject to damage and damage to element(s) would impede the per-
formance of this and other components, systems, or operations; Average = Subject to damage but damage to element(s)
would not impede function; High = No or minor potential for damage that would impede the performance of this and
other components, systems, or operations.

70. Condition and safety of roofing

The evaluators should go up on the roof of the hospital to make a thorough assessment. It is ad-
visable to begin with the roofing on the highest part of the hospital, since from this vantage point it is
possible to get a general idea of the condition of lower areas. The evaluators can then concentrate on a
more detailed evaluation where problems are obvious. Impermeability, equipment located on the roof,
and drainage are among the aspects that need the evaluator’s attention. Leakage from water systems on
the roof can put a hospital or sections of the hospital out of service. When the affected areas are the
most critical ones, consequences are major. The location of equipment can affect the roof ’s vulnerability
to different natural forces.
Safety ratings for item No. 70 are: Low = Subject to damage and damage to element(s) would impede
the performance of this and other components, systems, or operations; Average = Subject to damage but dam-
age to element(s) would not impede function; High = No or minor potential for damage that would impede
the performance of this and other components, systems, or operations.

71. Condition and safety of parapets (wall or railing placed to prevent falls on roof,
bridges, stairs, etc.)
This item is comparable to item 69 (elements of building envelope) in significance and the same
criteria should be used to review these elements. Evaluators should keep in mind the importance of these
elements in protecting stairways and passages in the hospital, considering whether their failure could

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endanger occupants of the hospital. Attention should be focused on areas where there is the highest con-
centration of people.
Safety ratings for item No. 71 are: Low = Subject to damage and damage to element(s) would impede
the performance of this and other components, systems, or operations; Average = Subject to damage but damage
to element(s) would not impede function; High = No or minor potential for damage that would impede the
performance of this and other components, systems, or operations.

72. Condition and safety of perimeter walls and fencing

Security of the hospital can be affected by the poor condition of walls and fencing that define the hos-
pital grounds. Without some level of control at the perimeter, disaster conditions will bring so many people
from the outside that it will make it difficult for the health services to function. The evaluators should check
this aspect in detail when surveying the hospital grounds. Evaluators will be able to see fencing and areas
neighboring the hospital when they are on the upper floors of the building, which will help them to make a
determination about problems in this area.
Safety ratings for item No. 72 are: Low = Subject to damage and damage to element(s) would impede
the performance of this and other components, systems, or operations; Average = Subject to damage but damage to
element(s) would not impede function; High = No or minor potential for damage that would impede the perfor-
mance of this and other components, systems, or operations.

73. Condition and safety of other outside elements (cornices, ornaments, etc.)
The same criteria outlined in items 69 and 71 can be used to evaluate these elements. Special at-
tention should be given to the condition of anchors and supports of exterior architectural elements.
Seismic shaking can cause them to fall, resulting in considerable damage and even deaths. It is not
advisable to use window boxes on the exterior of buildings, since besides the risk posed by falling, these
elements can increase seismic loads.
Safety ratings for item No. 73 are: Low = Element(s) subject to damage and damage would impede
the performance of this and other components, systems, or operations; Average = Element(s) subject to damage
but damage would not impede function; High = No or minor potential for damage that would impede the
performance of this and other components, systems, or operations.

74. Safe conditions for movement outside of building

Movement outside of the hospital must be ensured so that pedestrians, ambulances, and supply trans-
port can access the facility with the speed required during disasters. External obstacles to access can severely
disrupt the function of the facility. Evaluators should observe whether there are trees and lamp posts that
could fall because of natural forces and obstruct pedestrian and vehicle access to the facility. The condition of
pavement within the hospital grounds should be checked for potholes or other obstacles that could interrupt
pedestrian and vehicle traffic.
Safety ratings for item No. 74 are: Low = Damage to structure or road and walkways will impede access
to buildings or endanger pedestrians; Average = Damage to structure or road and walkways will not impede pe-

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destrian access, but will impede vehicle access; High = No or minor potential for slight damage which will impede
pedestrian or vehicle access.

75. Safe conditions for movement inside the building (corridors, stairs, elevators,
exit doors, etc.)
The evaluators must verify that conditions are safe for movement throughout the facility. Inside cor-
ridors should be spacious and free of obstacles to ensure ease of movement for personnel, stretchers, and
medical equipment. Special attention should be given to stairways and exits because of their importance
should evacuation occur during earthquakes or other emergencies. Adequate signage must be present to
facilitate movement of staff, patients, and visitors. Areas with restricted access should be under the surveil-
lance of hospital security personnel.
Safety ratings for item No. 75 are: Low = Subject to damage and damage to element(s) will impede
movement inside building and endanger occupants; Average = Damage to element(s) will not impede move-
ment of people but will impede movement of stretchers, wheeled equipment; High = No or minor potential
for slight damage which will impede movement of people or wheeled equipment.

76. Condition and safety of internal walls and partitions

Internal walls and partitions can be of masonry, glass, wood, aluminum, etc., and can be a com-
bination of these materials. The evaluators should review technical and construction aspects of these
elements to ensure they are not cracked, deformed, or loose. Interior walls should be adequately braced
by structural elements so that they can resist seismic shaking and wind forces. The evaluation of internal
walls should be more rigorous in critical areas such as intensive care units, emergency rooms, operating
theaters, laboratories, etc.
Safety ratings for item No. 76 are: Low = Element(s) subject to damage and damage would impede the
performance of this and other components, systems, or operations; Average = Element(s) subject to damage
but damage would not impede function; High = No or minor potential for damage that would impede the
performance of this and other components, systems, or operations.

77. Condition and safety of false or suspended ceilings

There are a wide variety of false or suspended ceilings used in buildings. Those made of metal are the
heaviest and cause the greatest damage should they fall. Because the bracing usually is not visible, evaluators
will request maintenance personnel to take some ceiling sections apart so the condition of the anchors can
be checked. In seismic zones both angled and vertical bracing should be used to brace ceilings from hori-
zontal seismic forces. In areas where these elements can be subjected to strong winds, they can fall, become
projectiles, collide with other objects, and, in the worst case, injure people. If they do fall, they can obstruct
passageways in the hospital, thus affecting its functional capacity.

IF THE HOSPITAL DOES NOT HAVE FALSE OR SUSPENDED CEILINGS,

LEAVE BOXES BLANK.

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Safety ratings for item No. 77 are: Low = Element(s) subject to damage and damage would impede the
performance of this and other components, systems, or operations; Average = Element(s) subject to damage
but damage would not impede function; High = No or minor potential for damage that would not impede
the performance of this and other components, systems, or operations.

78. Condition and safety of external and internal lighting systems

Lighting systems are one of the major non-structural elements in a hospital. If lighting does not func-
tion correctly, especially in critical areas, it will have a major effect on how the hospital functions. Evalua-
tors should ensure that both internal and external lighting is operational, correctly designed, and that any
area that needs lighting, has it. Evaluators should work with maintenance staff to determine whether there
is sufficient lighting supplies stock (for example, flashlights, lightbulbs) in case of disaster. They should
ensure that emergency lighting systems are adequate for the level and type of use of an area, especially in
the critical units of the hospital.
Safety ratings for item No. 78 are: Low = Element(s) subject to damage and damage would impede the
performance of this and other components, systems, or operations; Average = Element(s) subject to damage
but damage would not impede function; High = No or minor potential for damage that would not impede
the performance of this and other components, systems, or operations.

79. Condition and safety of fire protection system

The hospital must be completely protected against fire, since this type of hazard can stop services
in a hospital when they are most needed. Protection of patients and staff when there is a building fire
is of utmost concern. Evaluators will determine whether the hospital design incorporates fire walls,
which provide a high level of safety. They will also review the fire protection measures in areas at high-
est risk for fire, including boiler rooms, fuel tank storage, medical gases, electrical panel, documents,
pharmacy, etc. Fire extinguishing devices should be accessible and in usable condition. Expiration dates
on extinguishers should be checked. There must be a sufficient number of functional water hydrants,
and evaluators should confirm that these hydrants have a permanent supply of water so that they can
be used effectively in case of fire. Evaluators should confirm that personnel responsible for using the
equipment actually know how to use it.
Safety ratings for item No. 79 are: Low = Element(s) subject to damage and damage would impede the
performance of this and other components, systems, or operations; Average = Element(s) subject to damage
but damage would not impede function; High = No or minor potential for damage that would impede the
performance of this and other components, systems, or operations.

80. Condition and safety of elevator system

While elevators should not be used during a disaster, they play an important role after the event.
Evaluators will verify that the elevators function properly and can meet their load capacity. They should
take into account that they are the main means of transport for many patients, the elderly, and disabled.
When more than one elevator is out of service, especially in multi-storied structures, the functional capac-
ity of the facility is seriously affected.

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IF THERE ARE NO ELEVATORS, LEAVE BOXES BLANK.

Safety ratings for item No. 80 are: Low = Element(s) subject to damage and damage would impede the
performance of this and other components, systems, or operations; Average = Element(s) subject to damage
but damage would not impede function; High = No or minor potential for damage that would impede the
performance of this and other components, systems, or operations.

81. Condition and safety of stairways

Special attention should be given to the safety of stairways because of their importance in the case of
evacuation, for example, during an earthquake or in the case of a toxic gas leak. Evaluators should ensure
that they are free of obstacles or of items that could fall and obstruct them. They should have railings so
that they can be used safely at their maximum capacity, keeping in mind that hospital patients will be
more vulnerable than typical users.
Safety ratings for item No. 81 are: Low = Element(s) subject to damage and damage would impede the
performance of this and other components, systems, or operations; Average = Element(s) subject to damage
but damage would not impede function; High = No or minor potential for damage that would impede the
performance of this and other components, systems, or operations.

82. Condition and safety of floor coverings

Floors can be of a variety of materials, including terrazzo, ceramic or clay tile, linoleum, wood, etc.
They might be attached with adhesives, be laid over a membrane (such as a floating floor), or suspended.
The evaluator should verify that the flooring is watertight, anti-skid, and free of cracks or loose sections
especially in critical and high traffic areas. There should be no uneven sections or depressions that could
cause people to fall or cause carts and equipment to tip over. In areas where there are large numbers of
conduits or cables and suspended floors are used, evaluators should ensure that the flooring is braced to
resist lateral seismic loads.
Safety ratings for item No. 82 are: Low = Element(s) subject to damage and damage would impede the
performance of this and other components, systems, or operations; Average = Element(s) subject to damage
but damage would not impede function; High = No or minor potential for damage that would impede the
performance of this and other components, systems, or operations.

83. Hospital access routes

Access is essential if the hospital is to function properly. Evaluators need a detailed understanding of
the main access routes to the facility. Plans showing micro- and macro-locations of the hospital are help-
ful. The evaluators should determine the effectiveness of the hospital’s security and protection system in
terms of vehicle and pedestrian access. Interviews with hospital employees, patients, and, where possible,
people living near the facility, can provide information about the types of routes and at what hours routes
are congested. Evaluators should be observant of trees and structures along the access routes that would
impede traffic if they fell during a seismic event or hurricane. Alternative routes should be identified in

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case major access routes are obstructed. It is important to determine whether alternative routes are taken
into account in the hospital’s disaster preparedness and reduction plan. Evaluators should note the pres-
ence and condition of storm drains that service the area, and determine whether storm runoff would flood
certain routes, making them impassable.
Safety ratings for item No. 83 are: Low = Element(s) subject to damage and damage would impede the
performance of this and other components, systems, or operations; Average = Element(s) subject to damage
but damage would not impede function; High = No or minor potential for damage that would impede the
performance of this and other components, systems, or operations.

84. Other architectural elements, including emergency sigs

For this item, the evaluator will check any other architectural elements of the hospital that have not
been taken into account in previous items. For example, the chimneys for the facility’s incinerator should
be structurally sound, be capable of resisting seismic or wind loads, and have the stability required for their
height, whether they are self-supporting or braced. The evaluator should examine signs inside the hospital
that could fall and harm occupants or damage the facility. At this point, the evaluator will confirm that
evacuation routes are indicated both inside and outside of the hospital. The hospital’s security and protec-
tion personnel are responsible for directing and protecting everyone on hospital grounds in an emergency,
and must be fully aware of the hospital’s emergency signage.
Safety ratings for item No. 84 are: Low = Element(s) subject to damage and damage would impede the
performance of this and other components, systems, or operations; Average = Element(s) subject to damage
but damage would not impede function; High = No or minor potential for damage that would impede the
performance of this and other components, systems, or operations.

IV. Safety based on functional capacity of hospital

This module considers to what degree hospital personnel are prepared for major emergencies and
disasters how the hospital disaster plan has been put to use.
Evaluation objectives for this module are to determine:
• what physical aspects of the hospital should be considered for functional safety, and
• describe the relevant content of the Hospital Safety Index.
The standard that evaluators apply when looking at a facility is that the facility is organized and
ready to respond to major emergencies and disasters, and to manage mass casualties. Disaster response
should be detailed in the hospital’s existing contingency plan and procedures. Prior to an evaluation, it
is advisable for a hospital to conduct a self-evaluation, using the “Safe Hospitals Checklist.”

4.1 Organization of the Hospital Disaster Committee and the Emergency

Operations Center
Sub-module 4.1 evaluates the Hospital Disaster Committee with the aim of understanding its
functional organization and the Committee’s role in the Emergency Operations Center. The Commit-

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tee defines levels of authority, roles, and responsibilities within a facility, so activities are in line with
the institution’s goals and efforts are not duplicated. It promotes collaboration between individuals in
the group and improves efficiency and effectiveness of communications. This module addresses hospital
procedures used in major emergencies and disasters, evaluating efficiency (for example, as provided by
the action cards).

85. Committee has been formally established to respond to major emergencies or

disasters
Evaluators will obtain a copy of the Committee’s terms of reference and verify that the list of members
corresponds to current personnel.
Low = Committee does not exist; Average = Committee exists but is not functioning; High = Committee exists
and is functioning.

86. Committee membership is multi-disciplinary

Evaluators will verify that the positions on the Committee are occupied by personnel from diverse
disciplines (for example, hospital director, chief of nursing, maintenance engineer, head of emergency
services, medical director, chief of surgery, chief of laboratory and support services, among others).
Low = Three or less disciplines represented; Average = four or five disciplines represented; High = six or
more disciplines represented.

87. Each member is aware of his/her specific responsibilities

Evaluators will verify that members’ assigned responsibilities are in writing, describing their spe-
cific roles.
Low = Responsibilities not assigned; Average = Responsibilities have been officially assigned; High = All
members know and comply with their responsibilities.

88. Space is designated for the hospital Emergency Operations Centre (EOC)
Evaluators will verify that a room has been designated for operational command and that all
means of communication are installed (telephone, fax, Internet, etc.).
Low = Nonexistent; Average = Space has been officially assigned; High = EOC exists and is
functional.

89. The EOC is in a protected and safe location

Evaluators should take into account accessibility, safety, and protection when checking the room
used for the EOC.
Low = The room for the EOC is not in a safe location; Average = The EOC is in a safe location but it
is not easily accessible; High =The EOC is in a safe, protected, and easily accessible location.

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90. The EOC has a computer system and computers

Evaluators will ensure that the EOC has internet and intranet connections.
Low = No; Average = Incomplete; High = The EOC has all computer system requirements.

91. Both internal and external communications systems in the EOC function
properly
Evaluators will determine whether the switchboard (telephone central for re-routing calls) has a
paging or a public address system and that the operators know the emergency codes and how to use
them.
Low = Does not function or is nonexistent; Average = Partly functional; High = Complete and func-
tional.

92. The EOC has an alternative communications system

Evaluators will determine whether, besides the switchboard, there is an alternative communica-
tions system (e.g. cellular, two-way radio, etc.).
Low = Nonexistent; Average = Incomplete; High = Yes.

93. The EOC has adequate equipment and furnishings

Evaluators should verify that there are desks, chairs, power outlets, lighting, water supply, and
drainage.
Low = No; Average = Incomplete; High = Yes.

94. An up-to-date telephone directory is available in the EOC

Evaluators will confirm that the directory includes all support services needed in an emergency
(they should randomly check telephone numbers).
Low = No; Average = Directory exists but is not up-to-date; High = Available and current.

95. “Action Cards” available for all personnel

Evaluators should check that action cards describe the assigned duties of each hospital staff mem-
ber in case of an internal or external disaster.
Low = No; Average = Insufficient (numbers and quality); High = All staff members have cards.

4.2 Operational plan for internal or external disasters

This section evaluates the operational plan for internal or external disaster events.
This module evaluates whether the hospital disaster plan accomplishes the following:

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• Integrates the hospital plan with the community plan;

• Provides for cooperation with other services and institutions;
• Includes referral and counter-referral of patients (to and from other facilities);
• Takes into account technical and logistical support as appropriate for the type of organization
and complexity of the facility.
Evaluators should ensure that the plan addresses activities in different phases of the disaster cycle:
• Before: Plan, carry out risk reduction measures, and train.
• During: Activate the plan.
• After: Return to normal activities; evaluate the effectiveness of the plan.
The purpose of the disaster plan is to identify measures that should be put into practice before,
during, and after a disaster so that essential hospital services continue to function.

96. Strengthen essential hospital services

Evaluators should verify that the plan specifies actions to be taken before, during, and after a disaster in
the hospital’s critical services (emergency room, intensive care unit, sterilization unit, operating theater, among
others).
Low = Plan does not exist or exists only as a document; Average = Plan exists and personnel have been trained;
High = Plan exists, personnel have been trained, and resources are in place to carry out the plan.

97. Procedures to activate and deactivate the plan

Evaluators should appraise procedures for how, when, and by whom the plan is activated/deacti-
vated. In particular, they should determine:
• what type of signal is used and the criteria for activating the plan;
• whether the hospital director is responsible for activating the plan, and
• whether activation is requested by civil defense and public safety agencies, a central agency
responsible for medical emergencies, or other outside entities.
These requesting bodies would typically provide information on the type of disaster, the number
and type of victims, and estimated time of arrival at the hospital.
Low = Plan does not exist or exists only as a document; Average = Plan exists and personnel have been
trained; High = Plan exists, personnel have been trained, and resources are in place to carry out the proce-
dures.

98. Special administrative procedures for disasters

Evaluators should verify that the plan includes procedures for contracting personnel and for procure-
ments in case of disaster. This would include staffing in essential services for the first 72 hours after an

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event. The plan should take into account costs for overtime, double shifts, weekend, night, and holiday
pay.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Plan exists, personnel have been trained, and resources are in place to carry out the
procedures.

99. Financial resources for emergencies are budgeted and guaranteed

The evaluators should verify that the hospital has a specific budget for use in disaster situations.
Evaluators should confirm the following:
• the budget is sufficient to implement measures outlined in the plan;
• cash is available for immediate purchases, and there is a list of suppliers that will extend credit
to the hospital;
• quantity and availability of electrical-medical equipment is known;
• additional financial resources are calculated annually for emergencies, based on local vulner-
ability, potential hazards for the hospital, and prior experience with disasters.
Low = Not budgeted; Average = Funds will cover less than 72 hours; High = Funds are guaranteed for
72 hours or more.

100. Procedures for expanding usable space, including the availability of extra beds
Evaluators should confirm that the plan identifies physical spaces that can be equipped to treat
mass casualties.
Low = Space for expansion has not been identified; Average = Space has been identified and personnel
have been trained to carry out the expansion; High = Procedures exist, personnel have been trained, and
resources are in place to carry out expansion of space.

101. Procedures for admission to the emergency department

Evaluators should verify that the plan specifies the places and personnel responsible for carrying
out triage.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exists, personnel have been trained, and resources are in place to imple-
ment them.

102. Procedures to expand emergency department and other critical services

Evaluators should verify that the plan includes measures for expanding hospital services (for ex-
ample, providing drinking water supply and power, managing wastewater).

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Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exists, personnel have been trained, and resources are in place to imple-
ment them.

103. Procedures to protect patients’ medical records

Evaluators will determine how the plan deals with safely moving medical and other critical records
for patients. It should be kept in mind that these are medical-legal records and are the source for clinical
progression of a patient.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

104. Regular safety inspections are conducted by the appropriate authority

Evaluators should note the expiration and/or refill dates of fire extinguishers and of flow tests for fire
hydrants. Logbooks recording equipment tests and dates of inspections by civil defense personnel should be
examined.
Low = Inspections do not occur; Average = Incomplete or outdated inspection; High = Inspections are complete
and up-to-date.

105. Procedures for hospital epidemiological surveillance

Evaluators should verify that the hospital’s Epidemiological Surveillance Committee has specific
procedures for disaster incidents or treatment of mass casualties.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

106. Procedures for preparing sites for temporary placement of dead bodies and for
forensic medicine
Evaluators should confirm that the plan includes specific arrangements for pathology and a site for
the placement of multiple cadavers.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

107. Procedures for triage, resuscitation, stabilization, and treatment

Evaluators should confirm the existence of procedures, level of training of the personnel and
availability of the necessary resources for the classification, resuscitation, stabilization, and treatment of
victims in cases of disasters.

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Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

108. Transport and logistics support

Evaluators should verify that the hospital has ambulances and other official vehicles available for
patient transport and logistics support.
Low = Ambulances and vehicles for logistic support are not available; Average = There are insufficient
vehicles; High = Appropriate vehicles in sufficient numbers are available.

109. Food rations for hospital staff during the emergency

Evaluators should confirm that there are measures for supplying food during the emergency and
that funds for food are included in the budget. They should consider requirements of ambulance staff,
the availability of extra rations for patients, staff, and people mobilized for the emergency. Evaluators
should also examine other measures in place for the general welfare of the personnel.
Low = Nonexistent; Average = Covers less than 72 hours; High = Guaranteed for at least 72 hours.

110. Duties assigned for additional personnel mobilized during the emergency
The plan includes specific instructions for assigning duties to the personnel external to the hospital
that is mobilized during the emergency in order to provide assistance, managerial, or administrative
support.
Low = Assignments do not exist or exist only in a document; Average = Duties are assigned and person-
nel have been trained; High = Duties are assigned, personnel have been trained, and resources are in place to
mobilize the personnel.

111. Measures to ensure the well-being of additional personnel mobilized during

the emergency
Evaluators will confirm that the plan identifies where emergency personnel can rest, drink, and eat.
Low = Nonexistent; Average = Measures cover less than 72 hours; High = Measures are ensured for at least
72 hours.

112. Cooperative arrangements with local emergency plan

Evaluators will review written arrangements regarding cooperation between the hospital and com-
munity authorities.
Low = No arrangements exist; Average = Arrangements exist but are not operational; High = Arrange-
ments exist and are operational.

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113. Mechanism to prepare a census of admitted patients and those referred to

other hospitals
Evaluators will review specific forms that facilitate the listing of patients during emergencies.
Low = Mechanism does not exist or exists only as a document; Average = Mechanism exists and person-
nel have been trained; High = Mechanism exists, personnel have been trained, and resources are in place to
carry out the census.

114. System for referral and counter-referral of patients

The plan includes specific procedures for the transfer and reception of patients to and from other
health facilities inside and outside of the geographical area where the evaluated hospital is located.
Low = System does not exist or exists only as a document; Average = System exists and personnel have
been trained; High = System exists, personnel have been trained, and resources are in place to carry out the
plan.

115. Procedures for communicating with the public and media

Evaluators will appraise who is responsible for communicating with the public and media in case
of disaster (generally the person who is highest in the chain of command at the time of the event).
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

116. Procedures for response during evening, weekend, and holiday shifts
Evaluators should verify that there are response procedures for nights, weekends, and holidays in
case of emergencies and disasters.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

117. Procedures for the evacuation of the facility

Evaluators will examine plans to evacuate patients, visitors, and staff from the facility.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

118. Emergency and other exit routes are accessible

Evaluators will verify that exit routes are clearly marked and free of obstacles.

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Low = Exit routes are not clearly marked and many are blocked; Average = Some exit routes are marked and
most are clear of obstacles; High = All exit routes are clearly marked and free of obstacles.

119. Simulation exercises and drills

Evaluators will confirm that the plan is tested regularly through simulations and drills which are
evaluated and modified as appropriate.
Low = Plans are not tested; Average = Plans are tested, but not each year; High = Plans are tested an-
nually and updated according to the results of the exercises.

4.3 Contingency plans for medical treatment in disasters

120. Earthquakes, tsunamis, volcanoes, and landslides

The evaluators should review the corresponding plan and confirm if the personnel know how to
carry out its functions and if the hospital has the necessary resources to implement the plan.

IF THESE HAZARDS DO NOT EXIST WHERE THE HOSPITAL IS LOCATED,

LEAVE THE BOXES BLANK.

Low = Plan does not exist or exists only as a document; Average = Plan exists and personnel have been
trained; High = Plan exists, personnel have been trained, and resources are in place to carry out the plan.

121. Social conflict and terrorism

The evaluators should review the corresponding plan and confirm if the personnel know how to
carry out its functions and if the hospital has the necessary resources to implement the plan.
Low = Plan does not exist or exists only as a document; Average = Plan exists and personnel have been
trained; High = Plan exists, personnel have been trained, and resources are in place to carry out the plan.

122. Floods and hurricanes

The evaluators should review the corresponding plan and confirm if the personnel know how to
carry out its functions and if the hospital has the necessary resources to implement the plan.

IF THESE HAZARDS DO NOT EXIST WHERE THE HOSPITAL IS LOCATED,

LEAVE THE BOXES BLANK.

Low = Plan does not exist or exists only as a document; Average = Plan exists and personnel have been
trained; High = Plan exists, personnel have been trained, and resources are in place to carry out the plan.

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123. Fires and explosions

The evaluators should review the corresponding plan and confirm if the personnel know how to
carry out its functions and if the hospital has the necessary resources to implement the plan.
Low = Plan does not exist or exists only as a document; Average = Plan exists and personnel have been
trained; High = Plan exists, personnel have been trained, and resources are in place to carry out the plan.

124. Chemical accidents or exposure to ionizing radiation

The evaluators should review the corresponding plan and confirm if the personnel know how to
carry out its functions and if the hospital has the necessary resources to implement the plan.
Low = Plan does not exist or exists only as a document; Average = Plan exists and personnel have been
trained; High = Plan exists, personnel have been trained, and resources are in place to carry out the plan.

125. Pathogens with epidemic potential

The evaluators should review the corresponding plan and confirm if the personnel know how to
carry out its functions and if the hospital has the necessary resources to implement the plan.
Low = Plan does not exist or exists only as a document; Average = Plan exists and personnel have been
trained; High = Plan exists, personnel have been trained, and resources are in place to carry out the plan.

126. Psycho-social treatment for patients, families, and health workers

The evaluators should review the corresponding plan and confirm if the personnel know how to
carry out its functions and if the hospital has the necessary resources to implement the plan.
Low = Plan does not exist or exists only as a document; Average = Plan exists and personnel have been
trained; High = Plan exists, personnel have been trained, and resources are in place to carry out the plan.

127. Control of infections acquired during hospitalization

Evaluators should request the corresponding hospital manual and verify whether infection control
measures are in force.
Low = Manual does not exist or exists only as a document; Average = Manual exists and personnel have
been trained; High = Manual exists, personnel have been trained, and resources are available to implement
measures.

4.4 Plans for the operation, preventive maintenance, and restoration of critical
services
This sub-module aims to determine whether essential documentation relating to emergency re-
sponse is available, accessible, and relevant.

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128. Electric power supply and back-up generators

Evaluators should review the operations manual for the back-up electric generator as well as pre-
ventive maintenance records.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

129. Drinking water supply

Evaluators should review the operations manual for the water supply system as well as records on
preventive maintenance and water quality control.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

130. Fuel reserves

Evaluators should review the operations manual for fuel supplies, as well as preventive mainte-
nance records.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

131. Medical gases

Evaluators should review the operations manual for medical gases supply, as well as the preventive
maintenance records.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

132. Standard and back-up communications systems

The evaluators should review standards and procedures to maintain operation of routine and al-
ternate communication systems in case of emergencies and disasters.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

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133. Wastewater systems

Evaluators should confer with the maintenance division to ensure that hospital wastewater drains
into the public sewage system and does not contaminate drinking water.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

134. Solid waste management

Evaluators should review the operations manual for solid waste management, as well as records
showing waste collection and subsequent disposal.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

135. Maintenance of the fire protection system

The maintenance division should provide the operations manual for the fire protection systems,
as well as records showing preventive maintenance on fire extinguishers and fire hydrants. It should be
verified that the following is complied with:
• A manual and training on the management of fire protection systems are available. There are
records of preventive maintenance of extinguishers and hydrants.
• The equipment is to be found in the appropriate places and is freely accessible.
• The network of pipes, pumps and accessories is exclusively for the hydrants.
• Hoses are appropriately joined to the valves on the cabinets for the hydrants.
• The network of hydrants has its own water cistern.
• The fire brigade has been established.
• There are trained personnel and drills have been carried out.
• A plan of action is available.
• The material or inflammable liquids are stored in safe places used exclusively for these sub-
stances.
It is necessary to check that activities assigned to the brigade for controlling and mitigating fires are car-
ried out in accordance with plans. In general, the maintenance service is responsible for this brigade and it is
made up of at least 10 people from different shifts. This brigade draws up bulletins with basic recommenda-
tions to avoid fires and carries out visits to area of risk and identifies evacuation routes.
Low = Procedures do not exist or exist only in a document; Average = Procedures exist and personnel
have been trained; High = Procedures exist, personnel have been trained, and resources are in place to imple-
ment them.

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4.5 Availability of medicines, supplies, instruments, and other equipment for use in
emergency
The availability of essential supplies in the event of an emergency should be checked.

136. Medicines
Evaluators should verify the availability of medicines for emergencies. The WHO list of essential
drugs can be used as a reference.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply guaranteed for at least
72 hours.

137. Items for treatment and other supplies

Evaluators should confirm that the sterilization unit has a supply of sterilized materials for surgical
use in an emergency (evaluators can check the supply prepared for the following day).
Low = Nonexistent; Average = Supply cover less than 72 hours; High = Supply is guaranteed for at least
72 hours.

138. Instruments
Evaluators should verify the stock and maintenance of specific instruments used in emergencies.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply guaranteed for at least
72 hours.

139. Medical gases

Evaluators should check the phone numbers and addresses of medical gas suppliers and ensure that the
supplier can provide gases in an emergency.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply guaranteed for at least
72 hours.

140. Mechanical volume ventilators

The Hospital Disaster Committee should provide the evaluators with documentation on quantity
and conditions of use of this equipment and rate the safety level according with their availability in
disasters.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply guaranteed for at least
72 hours.

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141. Electro-medical equipment

The Hospital Disaster Committee should provide the evaluators with documentation on quantity
and conditions of use of this equipment and rate the safety level according with their availability in
disasters.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply guaranteed for at least
72 hours.

142. Life-support equipment

The Hospital Disaster Committee should provide the evaluators with documentation on quan-
tity and conditions of use of this equipment and rate the safety level according to their availability in
disasters.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply guaranteed for at least
72 hours.

143. Personal protection equipment for epidemics (disposable)

Evaluators should check the hospital’s stocks of personal protection equipment for staff working
in areas of initial contact and treatment.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply guaranteed for at least
72 hours.

144. Crash cart for cardiopulmonary arrest

The Hospital Disaster Committee should provide documentation on quantity, conditions of use,
and locations of crash carts for treatment of cardiopulmonary arrest and rate the safety level according
to their availability in disasters.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply guaranteed for at least
72 hours.

145. Triage tags and other supplies for managing mass casualties
The emergency department distributes and uses triage tags in case of mass casualties. Evaluators
should check the supply in terms of the maximum capacity of the hospital.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply guaranteed for at least
72 hours.

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 GLOSSARY6 11

Adverse event
Alterations in people, the economy, social systems and the environment, caused by natural phe-
nomena, generated by human activity or by the combination of both, that demands the immediate
response of the affected community. It can be an Emergency or a Disaster depending on damage mag-
nitude and response capacity.

Adverse events cycle

Prevention: Risk = 0
Mitigation: Risk = lowered
Preparation: Response capacity strengthened
Response: Humanitarian assistance
Rehabilitation: Provisional or temporary recovery
Reconstruction: Complete restoration

Critical services
Services that are life-saving, involve hazardous or harmful equipment or materials, or whose failure
may generate chaos and confusion among patients or staff.

Development
Cumulative and durable increase of quantity and quality of goods, services, and resources of a
community along with social changes aimed at maintaining or improving the safety and the quality of
human life without compromising the resources of the future generations

Disaster
Severe alterations on people’s life and wellbeing, goods, services, the economy, social systems and
the environment, caused by natural phenomena, generated by human activity or by the combination
of both, that exceeds the response capacity of the affected community.

Disaster management
Systematic process of planning, organization, direction and control of all disaster related activities.
Disaster Management is achieved through the implementation of prevention, mitigation, preparedness,
response, rehabilitation and reconstruction.

6 The terminology has been compiled from several sources and adapted to the PAHO/WHO work in technical advisory for disaster
reduction.
77
Disaster risk reduction
Set of measures aimed at minimizing the probability of damage caused by adverse phenomena at
such a level that needs can be covered with the affected community’s own resources. This is achieved by
eliminating (prevention) or reducing (mitigation) the hazard, the vulnerability or both, and increasing
in the community response capacity (preparedness).

Emergency
Intense alterations on people’s life and wellbeing, goods, services, the economy, social systems and
the environment, caused by natural phenomena, generated by human activity or by the combination
of both, that can be solved using the affected community own resources.

Hazard
External risk factor represented by the potential occurrence of a phenomena or event of natural
origin, generated by human activity or a combination of both, that can occur in a specific place with a
given intensity and duration.

Mitigation
Set of actions aimed at reducing probable damage that may result from the interaction of hazard
and vulnerability. Mitigation is achieved by reducing the hazard, the vulnerability or both.

Nonstructural components
Elements that are not part of the load-bearing system of the building. They include architectural
elements and the equipment and systems needed for operating the facility. Among the most important
nonstructural components: architectural elements such as façades, interior partitions, roofing struc-
tures, and appendages. Nonstructural systems and components include lifelines; industrial, medical
and laboratory equipment; furnishings; electrical distribution systems; HVAC systems; and elevator/
escalator systems.

Nonstructural detailing
A set of measures, based on the theoretical, empirical, and experimental experience of the various
disciplines, aimed at protecting and improving the performance of nonstructural components.

Preparedness
Set of actions aimed at increasing the capacity to deal with damage caused by adverse phenomena,
timely and adequately organizing response and rehabilitation. Preparedness is achieved by elaborating
response plans, training involved personnel and establishing a reserve of resources needed to implement
the response.

78
 GLOSSARY

Prevention
Set of actions aimed to avoid or impede the occurrence of damages as a consequence of adverse
phenomena. Prevention is achieved by eliminating the hazard, the vulnerability or both.

Reconstruction
Process of complete restoration of the physical, social, and economic damage at a level of protec-
tion higher than that existing before the event. Reconstruction is achieved by incorporating disaster risk
reduction measures when restoring damaged infrastructure, systems and services.

Rehabilitation
Provisional or temporary restoration of the community essential services. Rehabilitation is achieved
by providing services at pre-disaster levels.

Relation between risk, hazard and vulnerability

The risk is the result of the interaction between hazard and vulnerability. This is a dynamic and
complex interaction that is modified in time according to the changes in the probability that a certain
phenomenon may occur in a given time and place with an identified intensity, magnitude and dura-
tion and the predisposition of people, infrastructure, services and goods that can be affected by that
phenomen. The simplification of the relation among these three factors finds expression in the formula:
R = H . V. Where R is risk, H is hazard and V is vulnerability.

Response
Actions taken in case of emergencies or disasters, or when damage is imminent, for the purpose
of saving lives, reducing suffering, and limiting economic and social losses through the mobilization of
humanitarian assistance to cover essential needs of the affected population.

Risk
Probability of social, environmental and economic damage in a specific community and in a given
period of time with a magnitude, intensity, cost and duration determined by the interaction between
hazard and vulnerability.

Safe Hospital
Health facility whose services remain accessible and functioning at maximum capacity and in the
same infrastructure, during and immediately following the impact of a natural hazard.

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Hospital Safety Index GUIDE FOR EVALUATORS

Structural components
Elements that are part of the resistant system of the structure, such as columns, beams, walls,
foundations, and slabs.

Structural detailing
Set of measures, based on the theoretical, empirical and experimental experience of the various
participating disciplines, for protecting and improving the structural component’s performance.

Vulnerability
lnternal risk factor of a subject, object or system, exposed to a hazard that corresponds to the de-
gree of predisposition or susceptibility to be damaged by that hazard.

80
 BIBLIOGRAPHY 12

1. Pan American Health Organization. Guidelines for vulnerability reduction in the design of new
health facilities. Washington, D. C.: OPS; 2004.
2. Pan American Health Organization. Safe Hospitals. A Collective Responsibility. A Global Measure
of Disaster Reduction. Washington, D. C.: OPS; 2005.
3. Pan American Health Organization. Curso de planeamiento hospitalario para casos de desastres.
Curso PHD. Washington, D. C.: OPS; 2005.
4. Pan American Health Organization. Manual de simulacros hospitalarios de emergencia. Washing-
ton, D. C.: OPS; 1995
5. Pan American Health Organization. Reducción del daño sísmico. Guía para las empresas de agua.
Serie Salud Ambiental y Desastres. Lima (Perú): OPS; 2003.
6. Pan American Health Organization. Principles of Disaster Mitigation in Health Facilities. Wash-
ington, D. C.: PAHO; 2000.
7. Ministry of Health of Nepal and World Health Organization. Guidelines on Non-Structural
Safety in Health Facilities. Kathmandu; 2004.
8. World Health Organization and National Society for Earthquake Technology – Nepal (NSET).
Guidelines for Seismic Vulnerability Assessment of Hospitals. Kathmandu; 2004.
9. National Society for Earthquake Technology-Nepal (NSET), Ministry of Health of Nepal
and World Health Organization. Non-structural Vulnerability Assessment of Hospitals in Nepal.
Kathmandu; 2003.
10. World Health Organization, Ministry of Health of Nepal and National Society for Earth-
quake Technology-Nepal (NSET). A Structural Vulnerability Assessment of Hospitals in Kath-
mandu Valley. Kathmandu; 2002.
11. Instituto Mexicano del Seguro Social, Secretaría de Gobernación de México, Organización
Panamericana de la Salud. Curso para Evaluadores del Programa Hospital Seguro. México DF;
2007.

81
 ANNEX 1 13

Form 1
General Information About the Health Facility

Please note:
This version of the form is for reference or consultation. To complete the evalua-
tion and fill out the information, photocopy the document included in the folder
(see: “Evaluation Forms for Safe Hospitals”), or if you prefer print the file included
in CD-ROM.

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Hospital Safety Index GUIDE FOR EVALUATORS

GENERAL INFORMATION ABOUT THE HEALTH FACILITY

1. Name of the facility: .................................................................................................................

2. Address: ....................................................................................................................................

. ...................................................................................................................................................

3. Telephone (include city code): ..................................................................................................

. ...................................................................................................................................................

4. Website and e-mail address: ......................................................................................................

. ...................................................................................................................................................

5. Total number of beds:...............................................................................................................

6. Hospital occupancy rate in normal situations: ..........................................................................

7. Description of the institution (general aspects, institution to which it belongs, type of establish-
ment, place in the network of health services, type of structure, population served, area of influence,
service and administrative personnel, etc.) .................................................................................. .

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

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 Form 1 GENERAL INFORMATION ABOUT THE HEALTH FACILITY

8. Physical distribution

List and briefly describe the main buildings in the facility. Provide a diagram in the box below
of the physical distribution of the services and the facility’s surroundings. Use additional pages,
if necessary.

. ......................................................................................................................................................

. ......................................................................................................................................................

. ......................................................................................................................................................

. ......................................................................................................................................................

. ......................................................................................................................................................

. ......................................................................................................................................................

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Hospital Safety Index GUIDE FOR EVALUATORS

9. Hospital capacity

Indicate the total number of beds and capacity to expand service in emergencies, according to the
hospital’s organization (by department or specialized services):

a. Internal medicine

Department or service Number of Additional Observations

beds capacity
General medicine
Pediatrics
Cardiology
Pneumology
Neurology
Endocrinology
Hematology
Gastroenterology
Dermatology
Physiology and rehabilitation
Psychiatry
Others, specify
Others, specify
Others, specify
Total

b. Surgery

Departament or service Number of Additional Observations

beds capacity
General surgery
Obstetrics and gynecology
Orthopedics and traumatology
Urology
Otolaryngology
Ophtalmology
Neurosurgery
Plastic surgery
Cardiovascular surgery
Others, specify
Total

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 Form 1 GENERAL INFORMATION ABOUT THE HEALTH FACILITY

c. Intensive Care Unit (ICU)

Departament or service Number of Additional Observations

beds capacity
General intensive care
General intermediate care
Cardiovascular ICU
Pediatrics ICU
Others, specify
Total

d. Operating theaters

Type of operating theaters Number of Additional Observations

operating capacity
theaters
Septic surgery
Aseptic surgegy
Pediatrics surgery
Obstetrics and gynecology
surgery
Emergency surgery
Others, specify
Total

10. Areas likely to increase operating capacity

Indicate the characteristics of the areas and spaces that can be used to increase hospital capacity in case
of an emergency or disaster. Specify square meters, available services and any other information that
can be used to evaluate its suitability for emergency medical services.

Water Electricity Telephone Observations

Areas Area m2
Yes No Yes No Yes No

Note: Specify the adaptability of use in each space: hospitalization, triage, ambulatory care, observa-
tion, etc.

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Hospital Safety Index GUIDE FOR EVALUATORS

11. Additional information

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

. ...................................................................................................................................................

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 ANNEX 2 14

Form 2
Safe Hospitals Checklist

Notice:
This form should be distributed to all members of the evaluating team. For this
purpose, do not use the version included in this document, which only serves as
a reference or consultation tool; the form included in the folder should be photo-
copied (see “Evaluation Forms for Safe Hospitals”) or, if you prefer, print directly
from CD-ROM included.

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Hospital Safety Index GUIDE FOR EVALUATORS

Hazard Level
1.1 Hazards
Refer to hazard maps. Request the Hospital Disaster Committee to No Hazard level OBSERVATIONS
provide the map(s) showing safety hazards at the site of the building. hazard LOW AVERAGE HIGH

1.1.1 Geological phenomena

Earthquakes
Rate the hazard level of the hospital in terms of geotechnical soil analyses.
Volcanic eruptions
Refer to hazard maps of the region to rate the hospital’s exposure to
hazard in terms of its proximity to volcanoes, volcanic activity, routes of
lava flow, pyroclastic flow, and ash fall.
Landslides
Refer to hazard maps to rate the level of hazard for the hospital in terms
of landslides caused by unstable soils (among other causes).
Tsunamis
Refer to hazard maps to rate the level of hazard for the hospital in terms
of previous tsunami events caused by submarine seismic or volcanic
activity.
Others (specify) ...............................................................................................................
Refer to hazard maps to identify other geological phenomena not listed
above. Specify the hazard and rate the corresponding hazard level for the
hospital.
1.1.2 Hydro-meteorological phenomena
Hurricanes
Refer to hazard maps to rate the hazard level of the hospital in terms of
hurricanes. It is helpful to take into account the history of such events
when rating the hazard level of the facility.
Torrential rains
Rate the hazard level for the hospital in relation to flooding due to inten-
sive rainfall, based on the history of such events.
Storm surge or river flooding
Rate the hospital’s level of exposure to storm surge or river flooding
hazards based on previous events that did or did not cause flooding in or
around the hospital.
Landslides
Refer to geological maps to rate the hospital’s level of exposure to land-
slide hazards caused by saturated soil.
Others (specify) ...............................................................................................................
Refer to hazard maps to identify other hydro-meteorological hazards not
listed above. Specify the hazard and rate the corresponding hazard level
for the hospital.
1.1.3 Social phenomena
Population gatherings
Rate the hospital’s exposure to hazard in relation to the type of popula-
tion it serves, its proximity to population gatherings and prior events that
have affected the hospital.
Displaced populations
Rate the hospital’s exposure to hazard in terms of people who have been
displaced as a result of war, socio-political circumstances, or due to im-
migration and emigration.
Others (specify) ..............................................................................................................
If other social phenomena affect the safety of the hospital, specify them
and rate the level of hazard for the hospital accordingly.

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 Form 2 SAFE HOSPITAL CHECKLIST

1.1.4 Environmental phenomena

Epidemics
With reference to any past incidents at the hospital and specific pathogens,
rate the hospital’s exposure to hazards related to epidemics.
Contamination (systems)
With reference to any past incidents involving contamination, rate the
hospital’s exposure to hazards from contamination of its systems.
Infestations
With reference to the location and past incidents at the hospital, rate the
hospital’s exposure to hazards from infestations (flies, fleas, rodents, etc.).
Others (specify) .............................................................................................................
With reference to any past incidents at the hospital, specify any other
environmental phenomena not included above that might compromise
the level of safety of the hospital.
1.1.5 Chemical and/or technological phenomena
Explosions
With reference to the hospital’s surroundings, rate the hospital’s exposure
to explosion hazards.
Fires
With reference to the exterior of the hospital building, rate the hospital’s
exposure to external fires.
Hazardous material spills
With reference to the hospital’s surroundings, rate the hospital’s exposure
to hazardous material spills.
Others (specify) .............................................................................................................
Specify and rate other chemical or technological hazards in the area
where the hospital is located.

1.2 Geotechnical properties of soils

Liquefaction
With reference to the geotechnical soil analysis at the hospital site, rate
the level of the facility’s exposure to hazards from saturated and loose
subsoil.
Clay soils
With reference to soil maps, rate the hospital’s exposure to hazards from
clay soil.
Unstable slopes
Refer to geological maps and specify the hospital’s exposure to hazards
from the presence of slopes.

Comments on the results of Form 2, Module 1. The evaluator should use the space below to comment on the results of this module (1),

and provide his/her name and signature. .................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

Name/signature of evaluator .............................................................................................................................................................................................................................................

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Hospital Safety Index GUIDE FOR EVALUATORS

Safety level
2.1 Prior events affecting hospital safety OBSERVATIONS
LOW AVERAGE HIGH

1. Has there been prior structural damage to the hospital as a result

of natural phenomena?
Determine whether structural reports indicate that the level of safety
has been compromised. IF SUCH AN EVENT HAS NOT OCCURRED IN THE
VICINITY OF THE HOSPITAL, LEAVE BOXES BLANK.
Low = Major damage; Average = Moderate damage; High =Minor damage.
2. Was the hospital built and/or repaired using current safety
standards?
Verify whether the building has been repaired, the date of repairs, and
whether
repairs were carried out using standards for safe buildings.
Low = Current safety standards not applied; Average = Current safety stan-
dards partially applied; High = Current safety standards fully applied.
3. Has remodelling or modification affected structural behavior of
the facility?
Verify whether modifications were carried out using standards for safe
buildings.
Low = Major remodelling or modifications have been carried out; Average =
Moderate remodelling and/or modifications; High = Minor remodelling and/
or modifications or no modifications were carried out.
2.2 Safety of the structural system and type of Safety level
OBSERVATIONS
materials used in the building LOW AVERAGE HIGH

4. Condition of the building

Low = Deterioration caused by weathering; cracks on the first floor and irregu-
lar height of buildings; Average = Deterioration caused only by weathering;
High = Good; no deterioration or cracks observed.
5. Construction materials used
Low = Rust with flaking; cracks larger than 3mm; Average = Cracks between 1
and 3 mm or rust powder present; High = Cracks less than 1 mm; no rust.
6. Interaction of non-structural elements with the structure
Low = separation of less than 0.5% of the height of the partition/joint; Average
= separation between 0.5 and 1.5% of the height of the partition/joint; High =
separation above 1.5% of the partition/joint.
7. Proximity of buildings (hazards of pounding, wind tunnel effects,
fires, etc.)
Low = Separation is less than 0.5% of the height of the shorter of two adjacent
buildings; Average = Separation is between 0.5% and 1.5% of the height of
the shorter of two adjacent buildings; High = Separation is more than 1.5% of
the height of the shorter of two adjacent buildings.
8. Structural redundancy
Low = Fewer than three lines of resistance in each direction; Average = Three
lines of resistance in each direction or lines without orthogonal orientation;
High = More than three lines of resistance in each orthogonal direction of the
building.
9. Structural detailing, including connections
Low = Built before 1970; Average = Built between 1970 and 1990; High = Built
after 1990 and according to standards.
10. Safety of foundations
Low = Information is lacking or foundation depth is less than 1.5 m; Average
= Plans and soil studies are lacking but foundation depth is more than 1.5 m;
High = Plans, soil studies are available and foundation depth is more than 1.5
m.

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 Form 2 SAFE HOSPITAL CHECKLIST

11. Irregularities in the plan (rigidity, mass, and resistance)

Low = Shapes are irregular and structure is not uniform; Average = Shapes are
irregular but structure is uniform; Average = Shapes are regular, structure has
uniform plan, and there are no elements that would cause torsion.
12. Irregularities in height (rigidity, mass, and resistance)
Low = Height of storeys differs by more than 20% and there are significant
discontinuous or irregular elements; Average = Storeys have similar heights
(they differ by less than 20% but more than 5%) and there are few discontinu-
ous or irregular elements; High = Storeys of similar height (they differ by less
than 5%); there are no discontinuous or irregular elements.
13. Structural resilience to various phenomena (meteorological,
geological, among others)
Estimate structural behavior in response to different hazards or dangers,
other than earthquakes.
Low = Low structural resilience to natural hazards present at the site of the
hospital; Average = Satisfactory structural resilience; High = Excellent struc-
tural resilience.

Comments on the results of Form 2, Module 2:

................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................

Name/signature of evaluator ..............................................................................................................................................................................................................................................

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Hospital Safety Index GUIDE FOR EVALUATORS

3. Elements related to non-structural safety

Non-structural elements do not form part of the load-bearing system of the building. They include architectural components, equip-
ment, and systems that are necessary for the operation of the building.

Safety level
3.1 Critical systems OBSERVATIONS
LOW AVERAGE HIGH

3.1.1 Electrical system

14. Generator has capacity to meet 100% of demand
Verify that the generator begins to operate within seconds of the hospital
losing power, covering power demands for the entire hospital, particu-
larly in the emergency department, intensive care unit, sterilization unit,
operating theatres, etc.
Low = Generator can only be started manually or covers 0–30% of demand;
Average = Generator starts automatically in more than 10 seconds or covers
31%–70% of demand; High = Generator starts automatically in less than 10
seconds and covers 71%–100% of demand.
15. Regular tests of generator performance are carried out in critical
areas
Determine the frequency of generator performance tests that have
satisfactory results.
Low = Tested every 3 months or more; Average = Tested every 1 to 3 months;
High = Tested at least monthly.
16. Generator protected from damage due to natural phenomena
Low = No; Average = Partially; High = Yes.
17. Safety of electrical equipment, cables, and cable ducts
Low = No; Average = Partially; High = Yes.
18. Redundant system for local electric power supply
Low = No; Average = Partially; High = Yes.
19. Protection for control panel, overload breaker switch, and cables
Check the accessibility as well as condition and operation of the central
electrical control panel.
Low = No; Average = Partially; High = Yes.
20. Lighting system for critical areas of the hospital
Review lighting for emergency unit, intensive care unit, operating the-
atres, etc., testing the level of lighting in rooms and function of lighting
fixtures.
Low = No; Average = Partially; High = Yes.
21. External electrical systems installed on hospital grounds
Verify the existence and capacity of external substations that provide
power to the hospital.
Low = No electrical substations installed on hospital’s grounds; Average =
Substations installed but do not provide enough power to hospital; High =
Electrical substations installed and provide enough power to the hospital.
3.1.2 Telecommunications system
22. Condition of antennas and antenna bracing
Verify the condition of antennas and their bracing/supports.
Low = Poor or does not exist; Average = Satisfactory; High = Good.
23. Condition of low-voltage systems (Internet and telephone con-
nections/cables)
Verify that cables are properly connected in strategic areas to avoid
system overload.
Low = Poor or does not exist; Average = Satisfactory; High = Good.
24. Condition of alternative communications systems
Verify the condition of other communications systems: radio communica-
tions, satellite telephone, Internet, etc.
Low = Poor or does not exist; Average = Satisfactory; High = Good.

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 Form 2 SAFE HOSPITAL CHECKLIST

25. Condition of anchors and braces for telecommunications equip-

ment and cables
Verify that telecommunications equipment (radios, satellite telephone,
video conferencing system, etc.) is anchored for increased security.
IF THE SYSTEM DOES NOT NEED ANCHORS OR BRACING, LEAVE BOXES
BLANK.
Low = Poor; Average = Satisfactory; High = Good.
26. Condition of external telecommunications systems installed on
hospital grounds
Verify that external telecommunications systems do not interfere with
communications of the hospital.
Low = External telecommunications systems cause major interference with
hospital communications; Average = External telecommunications systems
cause moderate interference with hospital communications; High = External
communications cause no interference with hospital communications.
27. Site has adequate conditions for telecommunications systems
Low = Poor or does not exist; Average = Satisfactory; High = Good.
28. Safety of internal communications systems
Verify the condition of loudspeakers, public address system, speaker
systems, etc.
Low = Poor or does not exist; Average = Satisfactory; High = Good.
3.1.3 Water supply system
29. Water tank has permanent reserve that is sufficient to provide at
least 300 liters daily, per bed, for 72 hours
Verify that water storage is sufficient to satisfy user demand for three days.
Low = Sufficient for 24 hours or less; Average = Sufficient for more than 24
hours but less than 72 hours; High = Guaranteed to cover at least 72 hours.
30. Water storage tanks are protected and in secure locations
Visit the water tanks to determine the safety of the installations and of the
site.
Low = The site is susceptible to structural or non-structural failure; Average =
Failure would not cause collapse of tank; High = Low possibility of functional
failure.
31. Alternative water supply to major distribution network
Identify the agency or mechanism to supply or restore water service to
the hospital should the public water system fail.
Low = Provides less than 30% of demand; Average = Provides 30% to 80% of
demand; High = Provides more than 80% of daily demand.
32. Condition of water distribution system
Verify condition and proper performance of water distribution system,
including storage tanks, valves, pipes, and connections.
Low = Less than 60% are in good operational condition; Average = Between
60% and 80% are in good condition; High = Above 80% are in good condition.
33. Supplementary pumping system
Identify the existence and operation of the supplementary pumping
system in case water supply is interrupted.
Low = There is no back-up pump and operational capacity does not meet daily
demand; Average = All pumps are in satisfactory condition; High = All pumps
and back-up systems are operational.
3.1.4 Fuel storage (gas, gasoline, diesel)
34. Fuel tanks have at least 5-day capacity
Verify that the hospital has fuel storage tanks of adequate size and safety.
Low = Fuel storage is not secured and has less than 3-day fuel capacity; Aver-
age =Fuel storage has some security and has 3-5 days fuel capacity; High =
Fuel storage is secure and has capacity for 5 or more days.

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Hospital Safety Index GUIDE FOR EVALUATORS

35. Fuel tanks and/or cylinders are anchored and in a secure location
Low = There are no anchors and the tank enclosure is unsafe; Average =
Anchors are inadequate; High = Anchors are in good condition and the tank
enclosure is adequate.
36. Safe location of fuel storage
Verify that the tanks containing combustible liquids are accessible but at
a safe distance from the hospital.
Low = There is risk of failure and that tanks are not accessible; Average = One
of the two conditions have been met; High = The fuel storage tanks are acces-
sible and they are located in a secure site.
37. Safety of the fuel distribution system (valves, hoses, and
connections)
Low = Less than 60% of system is in good operational condition; Average =
between 60% and 80% of system is in good operational condition; High =
More than 80% of system is in good operational condition.
3.1.5 Medical gases (oxygen, nitrogen, etc.)
38. Sufficient medical gas storage for minimum of 15-day supply
Low = Less than 10-day supply; Average = Supply for between 10 and 15 days;
High = Supply for at least 15 days.
39. Anchors for medical gas tanks, cylinders, and related equipment
Low = Anchors are lacking; Average = Quality of anchors is inadequate; High =
Anchors are of good quality.
40. Availability of alternative sources of medical gases
Low = Alternative sources are lacking or are below standard; Average = Alterna-
tive sources exist and are in satisfactory condition; High = Alternative sources
exist and are in good condition.
41. Appropriate location for storage of medical gases
Low = Storage is not accessible; Average = Storage is accessible but hazards
exist; High = Storage is accessible and there are no hazards.
42. Safety of medical gas distribution system (valves, pipes,
connections)
Low = Less than 60% of system is in good working condition; Average =
Between 60% and 80% of system is in good working condition; High = More
than 80% of system is in good working condition.
43. Protection of medical gas tanks and/or cylinders and related
equipment
Low = No areas are used exclusively for this equipment and there are no
qualified personnel to operate it; Average = Areas are used exclusively for this
equipment but personnel are not trained to operate it; High = There are areas
used exclusively for this equipment AND it is operated by qualified personnel.
44. Adequate safety in storage areas
Low = No areas are reserved for storage of medical gases; Average = Areas are
reserved for storage of medical gases but safety measures are inadequate; High
= There are areas reserved for storage of medical gases and the site does not
present risks.
3.2 Heating, ventilation, and air-conditioning (HVAC) Safety level
OBSERVATIONS
systems in critical areas LOW AVERAGE HIGH

45. Adequate supports for ducts and review of flexibility of ducts and
piping that cross expansion joints
Low = Supports are lacking and connections are rigid; Average = Supports are
present or connections are flexible; High = Supports are present and connec-
tions are flexible.
46. Condition of pipes, connections, and valves
Low = Poor; Average = Satisfactory; High = Good.

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 Form 2 SAFE HOSPITAL CHECKLIST

47. Condition of anchors for heating and/or hot water equipment

Low = Poor; Average = Satisfactory; High = Good.
48. Condition of anchors for air-conditioning equipment
Low = Poor; Average = Satisfactory; High = Good.
49. Location of enclosures for HVAC equipment
Low = Poor; Average = Satisfactory; High = Good.
50. Safety of enclosures for HVAC equipment
Low = Poor; Average = Satisfactory; High = Good.
51. Operating condition of HVAC equipment (boiler, air-conditioning
systems, exhaust, etc.)
Low = Poor; Average = Satisfactory; High = Good.
3.3 Office and storeroom furnishings and equipment Safety level
(fixed and movable) including computers, printers, OBSERVATIONS
LOW AVERAGE HIGH
etc.
52. Anchors for shelving and safety of shelf contents
Verify that shelves are anchored to the walls and/or are braced and that
contents are secured.
Low = Shelving is not attached to walls; Average = Shelving is attached
but contents are not secured; High = Shelving is attached and contents are
secured.
53. Safety of computers and printers
Verify that computer tables are anchored and table wheels are locked.
Low = Poor; Average = Satisfactory; High = Good or does not require anchor.
54. Condition of office furnishings and other equipment
Check anchors and/or bracing on furnishings in offices.
Low = Poor; Average = Satisfactory; High = Good or does not require anchor.
3.4 Medical and laboratory equipment and supplies Safety level
OBSERVATIONS
used for diagnosis and treatment LOW AVERAGE HIGH

55. Medical equipment in operating theaters and recovery rooms

Verify that lamps, equipment for anaesthesia, and surgical tables are opera-
tional and that table or cart wheels are locked.
Low = The equipment is in poor condition or it is not secured; Average = The
equipment is in fair condition or not properly secured; High = Equipment is in
good condition and is secured.
56. Condition and safety of radiology and imaging equipment
Verify that the X-ray and imaging equipment is in good condition and is
secured.
Low = The equipment is in poor condition or it is not secured; Average = The
equipment is in fair condition or not properly secured; High = Equipment is in
good condition and is secured.
57. Condition and safety of laboratory equipment
Low = The equipment is in poor condition or it is not secured; Average = The
equipment is in fair condition or not properly secured; High = Equipment is in
good condition and is secured.
58. Condition and safety of medical equipment in emergency servi-
ces unit
Low = The equipment is in poor condition or it is not secured; Average = The
equipment is in fair condition or not properly secured; High = Equipment is in
good condition and is secured.
59. Condition and safety of medical equipment in intensive or inter-
mediate care unit
Low = The equipment is in poor condition or it is not secured; Average = The
equipment is in fair condition or not properly secured; High = Equipment is in
good condition and is secured.

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60. Condition and safety of equipment and furnishings in the phar-

macy
Low = The equipment is in poor condition or it is not secured; Average = The
equipment is in fair condition or not properly secured; High = Equipment is in
good condition and is secured.
61. Condition and safety of equipment in the sterilization unit
Low = The equipment is in poor condition or it is not secured; Average = The
equipment is in fair condition or not properly secured; High = Equipment is in
good condition and is secured.
62. Condition and safety of medical equipment for neonatal care
Low = The equipment is lacking, is in poor condition, or is not secured; Average
= The equipment is in fair condition or not properly secured; High = Equip-
ment is in good condition and is secured.
63. Condition and safety of medical equipment and supplies for burn
management
Low = The equipment is lacking, is in poor condition, or it is not secured; Average
= The equipment is in fair condition or not properly secured; High = Equipment is
in good condition and is secured.
64. Condition and safety of medical equipment for nuclear medicine
and radiation
therapy
IF THE HOSPITAL DOES NOT HAVE THESE SERVICES, LEAVE BOXES BLANK.
Low = The equipment is lacking, is in poor condition, or it is not secured;
Average = The equipment is in fair condition or not properly secured; High =
Equipment is in good condition and is secured.
65. Condition and safety of medical equipment in other services
Low = More than 30% of equipment is at risk of material or functional failure
and/or equipment puts the entire service’s operation at direct or indirect risk;
Average = Between 10% and 30% of equipment is at risk of loss; High = Less
than 10% of equipment is at risk of loss.
66. Anchors for shelving and safety of medical contents
Low = Shelves are anchored or shelf contents are secured in less than 20% of
cases; Average = Shelves are anchored or shelf contents are secured in 20% to
80% of cases; High = More than 80% of shelves are anchored and the contents
of shelves are secured (or shelving and contents do not require anchors).
Safety level
3.5 Architectural elements OBSERVATIONS
LOW AVERAGE HIGH

67. Condition and safety of doors and entrances

Low =Subject to damage and damage to element(s) would impede the perfor-
mance of this and other components, systems, or operations; Average = Sub-
ject to damage but damage to element(s) would not impede function; High =
No or minor potential for damage that would impede the performance of this
and other components, systems, or operations.
68. Condition and safety of windows and shutters
Low =Subject to damage and damage to element(s) would impede the perfor-
mance of this and other components, systems, or operations; Average = Sub-
ject to damage but damage to element(s) would not impede function; High =
No or minor potential for damage that would impede the performance of this
and other components, systems, or operations.
69. Condition and safety of other elements of the building envelope
(outside walls, facings, etc.)
Low =Subject to damage and damage to element(s) would impede the perfor-
mance of this and other components, systems, or operations; Average = Sub-
ject to damage but damage to element(s) would not impede function; High =
No or minor potential for damage that would impede the performance of this
and other components, systems, or operations.

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70. Condition and safety of roofing

Low =Subject to damage and damage to element(s) would impede the
performance of this and other components, systems, or operations; Average
= Subject to damage but damage to element(s) would not impede function;
High = No or minor potential for damage that would impede the perfor-
mance of this and other components, systems, or operations.
71. Condition and safety of parapets (wall or railing placed to prevent
falls on roofs, bridges, stairs, etc.)
Low =Subject to damage and damage to element(s) would impede the
performance of this and other components, systems, or operations; Average
= Subject to damage but damage to element(s) would not impede function;
High = No or minor potential for damage that would impede the perfor-
mance of this and other components, systems, or operations.
72. Condition and safety of perimeter walls and fencing
Low =Subject to damage and damage to element(s) would impede the perfor-
mance of this and other components, systems, or operations; Average = Subject
to damage but damage to element(s) would not impede function; High = No
or minor potential for damage that would impede the performance of this and
other components, systems, or operations.
73. Condition and safety of other outside elements (cornices, orna-
ments, etc.)
Low = Element(s) subject to damage and damage would impede the per-
formance of this and other components, systems, or operations; Average =
Element(s) subject to damage but damage would not impede function; High
= No or minor potential for damage that would impede the performance of
this and other components, systems, or operations.
74. Safe conditions for movement outside of building
Low = Damage to structure or road and walkways will impede access to
buildings or endanger pedestrians; Average = Damage to structure or road
and walkways will not impede pedestrian access, but will impede vehicle
access; High = No or minor potention for slight damage which will impede
pedestrian or vehicle access.
75. Safe conditions for movement inside the building (corridors,
stairs, elevators, exit doors, etc.)
Low = Subject to damage and damage to element(s) will impede movement
inside building and endanger occupants; Average = Damage to elements
will not impede movement of people but will impede movement of stretchers,
wheeled equipment; High = No or minor potential for slight damage which
will not impede movement of people or wheeled equipment.
76. Condition and safety of internal walls and partitions
Low = Element(s) subject to damage and damage would impede the per-
formance of this and other components, systems, or operations; Average =
Element(s) subject to damage but damage would not impede function; High =
No or minor potential for damage that would impede the performance of this
and other components, systems, or operations.
77. Condition and safety of false or suspended ceilings
IF THE HOSPITAL DOES NOT HAVE FALSE OR SUSPENDED CEILINGS, LEAVE
BOXES BLANK.
Low = Element(s) subject to damage and damage would impede the per-
formance of this and other components, systems, or operations; Average =
Element(s) subject to damage but damage would not impede function; High
= No or minor potential for damage that would impede the performance of
this and other components, systems, or operations.
78. Condition and safety of internal and external lighting systems
Low = Element(s) subject to damage and damage would impede the per-
formance of this and other components, systems, or operations; Average =
Element(s) subject to damage but damage would not impede function; High
= No or minor potential for damage that would impede the performance of
this and other components, systems, or operations.

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79. Condition and safety of fire protection system

Low = Element(s) subject to damage and damage would impede the per-
formance of this and other components, systems, or operations; Average =
Element(s) subject to damage but damage would not impede function; High
= No or minor potential for damage that would impede the performance of
this and other components, systems, or operations.
80. Condition and safety of elevator system
IF THERE ARE NO ELEVATORS, LEAVE BOXES BLANK.
Low = Element(s) subject to damage and damage would impede the per-
formance of this and other components, systems, or operations; Average =
Element(s) subject to damage but damage would not impede function; High
= No or minor potential for damage that would impede the performance of
this and other components, systems, or operations.
81. Condition and safety of stairways
Low = Element(s) subject to damage and damage would impede the per-
formance of this and other components, systems, or operations; Average =
Element(s) subject to damage but damage would not impede function; High
= No or minor potential for damage that would impede the performance of
this and other components, systems, or operations.
82. Condition and safety of floor coverings
B= Low = Element(s) subject to damage and damage would impede the
performance of this and other components, systems, or operations; Average =
Element(s) subject to damage but damage would not impede function; High =
No or minor potential for damage that would impede the performance of this
and other components, systems, or operations.
83. Hospital access routes
Low = Element(s) subject to damage and damage would impede the per-
formance of this and other components, systems, or operations; Average =
Element(s) subject to damage but damage would not impede function; High
= No or minor potential for damage that would impede the performance of
this and other components, systems, or operations.
84. Other architectural elements, including emergency signs
Low = Element(s) subject to damage and damage would impede the per-
formance of this and other components, systems, or operations; Average =
Element(s) subject to damage but damage would not impede function; High
= No or minor potential for damage that would impede the performance of
this and other components, systems, or operations.

Comments on the results of Form 2, Module 3:

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4. Safety based on functional capacity of hospital

The level of preparedness of hospital staff for major emergencies and disasters as well as the level of implementation of the hospital
disaster plan.

4.1 Organization of the Hospital Disaster Committee Level of

and the Emergency Operations Center. Assess the level of organization OBSERVATIONS
organization achieved by the Hospital Disaster Committee. LOW AVERAGE HIGH

85. Committee has been formally established to respond to major emer-

gencies or disasters
Obtain a copy of the Committee’s terms of reference and verify that the list
of members corresponds to current personnel.
Low = Committee does not exist; Average = Committee exists but is not
functioning; High = Committee exists and is functioning.
86. Committee membership is multi-disciplinary
Verify that the positions on the Committee are occupied by personnel
from diverse disciplines (for example, hospital director, chief of nursing,
maintenance engineer, head of emergency services, medical director, chief
of surgery, chief of laboratory and support services, among others).
Low = 0–3 disciplines represented; Average = 4–5 disciplines represented;
High = 6 or more disciplines represented.
87. Each member is aware of his/her specific responsibilities
Verify that members’ assigned responsibilities are in writing, describing
their specific roles.
Low = Responsibilities not assigned; Average = Responsibilities have been
officially assigned; High = All members know and comply with their
responsibilities.
88. Space is designated for the hospital Emergency Operations Cen-
tre (EOC)
Verify that a room has been designated for operational command and that all
means of communication are present (telephone, fax, Internet, etc.).
Low = Nonexistent; Average = Space has been officially assigned; High = EOC
exists and is functional.
89. The EOC is in a protected and safe location
Take into account accessibility, safety, and protection when checking the
room used for the EOC.
Low = The room for the EOC is not in a safe location; Average = The EOC is
in a safe location but it is not easily accessible; High =The EOC is in a safe,
protected, and easily accessible location.
90. The EOC has a computer system and computers
Verify that the EOC has Internet and intranet connections.
Low = No; Average = Incomplete; High = The EOC has all computer system
requirements
91. Both internal and external communications systems in the EOC
function properly
Determine whether the switchboard (telephone central for re-routing
calls) has a paging or a public address system and the operators know the
emergency codes and how to use them.
Low = Does not function or is nonexistent; Average = Partly functional; High =
Complete and functional.
92. The EOC has an alternative communications system
Determine whether, besides the switchboard, there is an alternative com-
munications system (e.g. cellular, two-way radio, etc.).
Low = Nonexistent; Average = Incomplete; High = Yes.

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93. The EOC has adequate equipment and furnishings

Verify that there are desks, chairs, power outlets, lighting, water supply,
and drainage.
Low = No; Average = Incomplete; High = Yes.
94. An up-to-date telephone directory is available in the EOC
Confirm that the directory includes all support services needed in an
emergency (randomly check telephone numbers).
Low = No; Average = Directory exists but is not up-to-date; High = Available
and current.
95. “Action Cards” available for all personnel
Verify that action cards describe the assigned duties of each hospital staff
member in case of an internal or external disaster.
Low = No; Average = Insufficient (numbers and quality); High = All staff
members have cards.
Level of
4.2 Operational plan for internal or external implementation OBSERVATIONS
disasters LOW AVERAGE HIGH

96. Strengthen essential hospital services

The plan specifies actions to be taken before, during, and after a disaster
in the hospital’s essential services (emergency room, intensive care unit,
sterilization unit, operating theatre, among others).
Low = Plan does not exist or exists only as a document; Average = Plan exists
and personnel have been trained; High = Plan exists, personnel have been
trained, and resources are in place to carry out the plan.
97. Procedures to activate and deactivate the plan
Verify that there are procedures for how, when, and by whom the plan is
activated/deactivated.
Low = Plan does not exist or exists only as a document; Average = Plan exists
and personnel have been trained; High = Plan exists, personnel have been
trained, and resources are in place to carry out the procedures.
98. Special administrative procedures for disasters
Verify that the plan includes procedures for contracting personnel and for
procurements in case of disaster.
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Plan exists, personnel
have been trained, and resources are in place to carry out the procedures.
99. Financial resources for emergencies are budgeted and
guaranteed
Verify that the hospital has a specific budget for use in disaster situations.
Low = Not budgeted; Average = Funds will cover less than 72 hours; High =
Funds are guaranteed for 72 hours or more.
100. Procedures for expanding usable space, including the availability
of extra beds
The plan identifies physical spaces that can be equipped to treat mass
casualties.
Low = Space for expansion has not been identified; Average = Space has been
identified and personnel have been trained to carry out the expansion; High
= Procedures exist, personnel have been trained, and resources are in place to
carry out expansion of space.
101. Procedures for admission to the emergency department
The plan specifies the places and personnel responsible for carrying out
triage.
Low = Procedures do not exis or exist only in a documentt; Average = Procedures
exist and personnel have been trained; High = Procedures exist, personnel have
been trained, and resources are in place to implement them.

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 Form 2 SAFE HOSPITAL CHECKLIST

102. Procedures to expand emergency department and other critical

services
The plan should indicate actions needed to expand hospital services (for
example, drinking water supply, power, wastewater).
Low = Procedures do not exist or exist only in a document; Average = Procedures
exist and personnel have been trained; High = Procedures exist, personnel have
been trained, and resources are in place to implement them.
103. Procedures to protect patients’ medical records
The plan indicates how medical and other critical patient records can be
safely moved.
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Procedures exist, person-
nel have been trained, and resources are in place to implement them.
104. Regular safety inspections are conducted by the appropriate
authority
Note the expiration and/or refill dates of fire extinguishers and of flow
tests for fire hydrants. Examine logbooks that record equipment tests and
dates of inspections by civil defence personnel.
Low = Inspections do not occur; Average = Incomplete or outdated inspection;
High = Inspections are complete and up-to-date.
105. Procedures for hospital epidemiological surveillance
Verify that the hospital’s Epidemiological Surveillance Committee has spe-
cific procedures for disaster incidents or treatment of mass casualties.
Low = Procedures do not exist or exist only in a document; Average = Procedures
exist and personnel have been trained; High = Procedures exist, personnel have
been trained, and resources are in place to implement them.
106. Procedures for preparing sites for temporary placement of dead
bodies and for forensic medicine
Verify that the plan includes specific arrangements for pathology and a
site for the placement of multiple cadavers.
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Procedures exist, person-
nel have been trained, and resources are in place to implement them.
107. Procedures for triage, resuscitation, stabilization, and treatment
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Procedures exist, person-
nel have been trained, and resources are in place to implement them.
108. Transport and logistics support
Confirm that the hospital has ambulances and other official vehicles.
Low = Ambulances and vehicles for logistic support are not available; Average
= There are insufficient vehicles; High = Appropriate vehicles in sufficient
numbers are available.
109. Food rations for hospital staff during the emergency
The plan specifies actions for supplying food during the emergency and
funds for these supplies are included in the budget.
Low = Nonexistent; Average = Covers less than 72 hours; High = Guaranteed
for at least 72 hours.
110. Duties assigned for additional personnel mobilized during the
emergency
Low = Assignments do not exist or exist only in a document; Average = Duties
are assigned and personnel have been trained; High = Duties are assigned,
personnel have been trained, and resources are in place to mobilize the
personnel.

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111. Measures to ensure the well-being of additional personnel mobili-

zed during the emergency
The plan identifies where emergency personnel can rest, drink, and eat.
Low = Nonexistent; Average = Measures cover less than 72 hours; High = Mea-
sures are ensured for at least 72 hours.
112. Cooperative arrangements with local emergency plan
There are written arrangements regarding cooperation between the
hospital and community authorities.
Low = No arrangements exist; Average = Arrangements exist but are not
operational; High = Arrangements exist and are operational.
113. Mechanism to prepare a census of admitted patients and those
referred to other hospitals
Low = Mechanism does not exist or exists only as a document; Average = Mecha-
nism exists and personnel have been trained; High = Mechanism exists, personnel
have been trained, and resources are in place to carry out the census.
114. System for referral and counter-referral of patients
Low = System does not exist or exists only as a document; Average = System
exists and personnel have been trained; High = System exists, personnel have
been trained, and resources are in place to carry out the plan.
115. Procedures for communicating with the public and media
The hospital disaster plan specifies who is responsible for communicating
with the public and media in case of disaster (generally the highest person
in the chain of command at the time of the event).
Low = Procedures do not exist or exist only in a document; Average = Procedures
exist and personnel have been trained; High = Procedures exist, personnel have
been trained, and resources are in place to implement them.
116. Procedures for response during evening, weekend, and holiday
shifts
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Procedures exist, person-
nel have been trained, and resources are in place to implement them.
117. Procedures for the evacuation of the facility
Verify procedures to evacuate patients, visitors, and staff.
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Procedures exist, person-
nel have been trained, and resources are in place to implement them.
118. Emergency and other exit routes are accessible
Verify that exit routes are clearly marked and free of obstacles.
Low = Exit routes are not clearly marked and many are blocked; Average =
Some exit routes are marked and most are clear of obstacles; High = All exit
routes are clearly marked and free of obstacles.
119. Simulation exercises and drills
The plan is tested regularly through simulations and drills, which are
evaluated and modified as appropriate.
Low = Plans are not tested; Average = Plans are tested, but not each year;
High = Plans are tested annually and updated according to the results of the
exercises.
Level of
4.3 Contingency plans for medical treatment in implementation OBSERVATIONS
disasters LOW AVERAGE HIGH

120. Earthquakes, tsunamis, volcanoes, and landslides

IF THESE HAZARDS DO NOT EXIST WHERE THE HOSPITAL IS LOCATED,
LEAVE THE BOXES BLANK.
Low = Plan does not exist or exists only as a document; Average = Plan exists
and personnel have been trained; High = Plan exists, personnel have been
trained, and resources are in place to carry out the plan.

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 Form 2 SAFE HOSPITAL CHECKLIST

121. Social conflict and terrorism

B= Low = Plan does not exist or exists only as a document; Average = Plan ex-
ists and personnel have been trained; High = Plan exists, personnel have been
trained, and resources are in place to carry out the plan.
122. Floods and hurricanes
IF THESE HAZARDS DO NOT EXIST WHERE THE HOSPITAL IS LOCATED,
LEAVE THE BOXES BLANK.
Low = Plan does not exist or exists only as a document; Average = Plan exists
and personnel have been trained; High = Plan exists, personnel have been
trained, and resources are in place to carry out the plan.
123. Fires and explosions.
Low = Plan does not exist or exists only as a document; Average = Plan exists
and personnel have been trained; High = Plan exists, personnel have been
trained, and resources are in place to carry out the plan.
124. Chemical accidents OR exposure to ionizing radiation
Low = Plan does not exist or exists only as a document; Average = Plan exists
and personnel have been trained; High = Plan exists, personnel have been
trained, and resources are in place to carry out the plan.
125. Pathogens with epidemic potential
Low = Plan does not exist or exists only as a document; Average = Plan exists
and personnel have been trained; High = Plan exists, personnel have been
trained, and resources are in place to carry out the plan.
126. Psycho-social treatment for patients, families, and health workers
Low = Plan does not exist or exists only as a document; Average = Plan exists
and personnel have been trained; High = Plan exists, personnel have been
trained, and resources are in place to carry out the plan.
127. Control of hospital-acquired infections
Request the corresponding hospital manual and verify whether control
procedures are in force.
Low = Manual does not exist or exists only as a document; Average = Manual
exists and personnel have been trained; High = Manual exists, personnel have
been trained, and resources are available to implement measures.
4.4 Plans for the operation, preventive maintenance, Level of
and restoration of critical services availability
OBSERVATIONS
Measure the level of availability, accessibility, and relevance of documents
LOW AVERAGE HIGH
that are essential when responding to an emergency.
128. Electric power supply and back-up generators
The maintenance division should provide the operations manual for the
back-up electric generator as well as preventive maintenance records.
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Procedures exist, person-
nel have been trained, and resources are in place to implement them.
129. Drinking water supply
The maintenance division should provide the operations manual for the
water supply system as well as records on preventive maintenance and
water quality control.
Low = Procedures do not exist or exist only in a document; Average = Procedures
exist and personnel have been trained; High = Procedures exist, personnel have
been trained, and resources are in place to implement them.
130. Fuel reserves
The maintenance division should provide the operations manual for fuel
supplies, as well as preventive maintenance records.
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Procedures exist, person-
nel have been trained, and resources are in place to implement them.

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131. Medical gases

The maintenance division should provide the operations manual for
medical gases supply, as well as preventive maintenance records.
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Procedures exist, person-
nel have been trained, and resources are in place to implement them.
132. Standard and back-up communications systems
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Procedures exist, person-
nel have been trained, and resources are in place to implement them.
133. Wastewater systems
The maintenance division should ensure that hospital wastewater drains
into the public sewage system and does not contaminate drinking water.
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Procedures exist, person-
nel have been trained, and resources are in place to implement them.
134. Solid waste management
The maintenance division should provide the operations manual for solid
waste management, as well as records showing waste collection and
subsequent disposal.
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Procedures exist, person-
nel have been trained, and resources are in place to implement them.
135. Maintenance of the fire protection system
The maintenance division should provide the operations manual for the
fire protection systems, as well as records showing preventive mainte-
nance on fire extinguishers and fire hydrants.
Low = Procedures do not exist or exist only in a document; Average = Proce-
dures exist and personnel have been trained; High = Procedures exist, person-
nel have been trained, and resources are in place to implement them.
4.5 Availability of medicines, supplies, instru- Level of
ments, and other equipment for use in emergency availability OBSERVATIONS
Verify the availability of essential supplies in the event of an emergency. LOW AVERAGE HIGH

136. Medicines
Check the availability of emergency medicines. The WHO list of essential
drugs can be used as a reference.
Low = Nonexistent; Average = Supplies cover less than 72 hours; High = Sup-
ply is guaranteed for at least 72 hours.
137. Items for treatment and other supplies
Check that the sterilization unit has a supply of sterilized materials for use in
an emergency (check the supply prepared for the following day).
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply
guaranteed for at least 72 hours.
138. Instruments
Verify the existence and maintenance of specific instruments used in
emergencies.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply
guaranteed for at least 72 hours.
139. Medical gases
Verify the phone numbers and addresses of medical gas supplier and
ensure availability in an emergency from the supplier.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply
guaranteed for at least 72 hours.
140. Mechanical volume ventilators
The Hospital Disaster Committee should provide documentation on
quantity and conditions of use of this equipment.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply
guaranteed for at least 72 hours.

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141. Electro-medical equipment

The Hospital Disaster Committee should provide documentation on
quantity and conditions of use of this equipment.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply
guaranteed for at least 72 hours.
142. Life-support equipment
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply
guaranteed for at least 72 hours.
143. Personal protection equipment for epidemics (disposable)
Verify the hospital’s stocks of personal protection equipment for staff
working in areas of initial contact and treatment.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply
guaranteed for at least 72 hours.
144. Crash cart for cardiopulmonary arrest
The Hospital Disaster Committee should provide documentation on
quantity, conditions of use, and locations of crash carts for treatment of
cardiopulmonary arrest.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply
guaranteed for at least 72 hours.
145. Triage tags and other supplies for managing mass casualties
The emergency department distributes and uses triage tags in case of mass
casualties.
Evaluate the supply in terms of the maximum capacity of the hospital.
Low = Nonexistent; Average = Supply covers less than 72 hours; High = Supply
guaranteed for at least 72 hours.

Comments on the results of Form 2, Module 4:

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Name/signature of evaluator .............................................................................................................................................................................................................................................

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