Hospital Safety Index: Item Weighting Information
Hospital Safety Index: Item Weighting Information
Hospital Safety Index: Item Weighting Information
IF SUCH AN EVENT HAS NOT OCCURRED IN THE VICINITY OF THE HOSPITAL, LEAVE BOXES BLANK.
Safety ratings: Low = Major remodelling or modifications have been carried out with major compromising effect
3 on the performance of the structure; Average = Moderate remodelling and/or modifications with minor effect on A 6.25
the performance of the structure; High = Minor remodelling and/or modifications; no modifications were carried
out; or major remodelling and/or modification enhancing the structural behaviour or having no negative effect.
6 Safety ratings: Low = Rust with flaking; cracks larger than 3 mm (concrete), excessive deformations (steel and A 6
wood); Average = Cracks between 1 and 3 mm present (concrete), moderate and visible deformations (steel and
wood) or rust with no flaking; High = Cracks less than 1 mm (concrete), no visible deformations; no rust.
15 Safety ratings: Low = Significant discontinuous or irregular elements, significant variation in elevation of A 3
buildings; Average = Several discontinuous or irregular elements, some variation in the elevation of buildings;
High = No significant discontinuous or irregular elements, little or no variation in elevation of buildings.
17 A 4.5
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17 Safety ratings: Low = Monopitch or flat light roofs, and/or large roof overhangs; Average = Pre-stressed concrete A 4.5
roof, gable roof with gentle slope, satisfactorily connected, no large roof overhangs; High = Reinforced cast in
place on concrete roof deck or hipped light roof, satisfactory connections, no large roof overhangs.
IF SUCH AN EVENT HAS NOT OCCURRED IN THE VICINITY OF THE HOSPITAL, LEAVE BOXES BLANK.
Safety ratings: Low = Windows and shutters in poor condition, subject to damage which would impede the
function of this and other elements, systems or operations (e.g. weak protective glazing); Average = In fair
21 condition, subject to damage but damage would not impede the function of this and other elements, systems or A 1
operations; High = In good condition, no or minor potential for damage that would impede the function of this and
other elements, systems or operations; protective glass (e.g. polycarbonate glazing, blast film) has been added
in critical wards.
Condition and safety of other elements of the building envelope (e.g. outside walls, facings)
Safety ratings: Low = Building envelope in poor condition, subject to damage which would impede the function of
22 this and other elements, systems or operations; Average = In fair condition, subject to damage but damage A 1
would not impede the function of this and other elements, systems or operations; High = In good condition, no or
minor potential for damage that would impede the function of this and other elements, systems or operations.
Safety ratings: Low = Roofing in poor condition, subject to damage which would impede the function of this and
23 other elements, systems or operations; Average = In fair condition, subject to damage but damage to element(s) A 2
would not impede function of this and other elements, systems or operations; High = In good condition, no or
minor potential for damage that would impede the function of this and other elements, systems or operations.
Safety ratings: Low = Railings and parapets in poor condition, subject to damage which would impede the
24 function of this and other elements, systems or operations; Average = Subject to damage but damage to A 1
element(s) would not impede the function of this and other elements, systems or operations; High = No or minor
potential for damage that would impede the function of this and other elements, systems or operations.
IF THE HOSPITAL DOES NOT HAVE FALSE OR SUSPENDED CEILINGS, LEAVE BOXES BLANK.
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Condition and safety of the elevator system
Safety ratings: Low = Elevator system in poor condition, subject to damage which would impede the function of
this and other elements, systems or operations; Average = In fair condition, element(s) subject to damage but
damage would not impede the function of this and other elements, systems or operations; High = In good
31 condition, no or minor potential for damage that would impede the function of this and other elements, systems A 1.2
or operations.
Safety ratings: Low = No protection measures taken; subject to damage, failure and disruption of critical services
34 and hospital operations in emergencies and disasters; Average = Partial measures to protect critical services A 2.5
from local hazards are taken; subject to damage with some disruption of critical services and hospital operations
in emergencies or disasters; High = Many measures are taken to protect critical services; high probability that
critical services and hospital will operate with no or limited disruption in emergencies and disasters.
40 Safety ratings: Low = No alternate sources; generators are in poor condition;, there are no protective measures; A 1.5
Average = Generators are in fair condition; some measures provide partial protection and security; High =
Generators are in good condition, well-secured and in good working order for emergencies.
43 Safety ratings: Low = Control panels or other elements are in poor condition, there are no protective measures; A 0.5
Average = Control panels or other elements are in fair condition; some measures provide partial protection; High
= Control panels or other elements are in good condition, well-protected and in good working order.
47 A 0.80
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Safety ratings: Low = Documented procedures and maintenance/inspection records do not exist; Average =
47 Documented procedures exist, maintenance/inspection records are up to date, personnel have been trained, but A 0.80
resources are not available; High = Documented procedures exist, maintenance/inspection records are up to
date, personnel have been trained, and resources are in place for implementing emergency maintenance and
restoration.
3.3.2 Telecommunication systems 5.00
Condition and safety of antennas
Safety ratings: Low = Antennas and bracing in poor condition, there are no protective measures; Average =
Antennas and bracing are in fair condition, some measures provide partial protection; High = Antennas and
48 bracing are in good condition, well-secured and protection measures are in place. A 0.4
52 Safety ratings: Low = External telecommunications systems cause major interference with hospital A 0.25
communications; Average = External telecommunications system cause moderate interference with hospital
communications; High = External communications cause no interference with hospital communications.
IF THE HOSPITAL DOES NOT HAVE A WATER STORAGE TANK, LEAVE BOXES BLANK.
Safety of the water distribution system
58 Safety ratings: Low = Less than 60% are in good operational condition; Average = Between 60% and 80% are in A 1.20
good condition; High = Above 80% are in good condition.
Alternative water supply to the regular water supply
59 Safety ratings: Low = Provides less than 30% of daily demand in an emergency or disaster scenario; Average = A 3.00
Provides 30−80% of daily demand in an emergency or disaster scenario; High = Provides more than 80% of
daily demand in an emergency or disaster scenario.
Supplementary pumping system
Safety ratings: Low = There is no back-up pump and operational capacity does not meet minimum daily demand;
60 Average = Supplementary pumps are in fair condition but would not meet the minimum daily demand for water; A 0.80
High = All supplementary pumps and back-up systems are operational and would meet the minimum demand for
water.
Emergency maintenance and restoration of water supply
Safety ratings: Low = Documented procedures and maintenance/inspection records do not exist; Average =
61 Documented procedures exist, maintenance/inspection records are up to date, personnel have been trained, but A 0.50
resources are not available; High = Documented procedures exist, maintenance/inspection records are up to
date, personnel have been trained, and resources are in place for implementing emergency maintenance and
restoration.
3.3.4 Fire protection system 7.50
Condition and safety of the fire protection (passive) system
Safety ratings: Low = Element(s) are subject to damage, and damage would impede the function of this and
62 other elements, systems or operations; Average = Element(s) are subject to damage but damage would not A 2.25
impede function; High = No or minor potential for damage that would impede the function of this and other
elements, systems or operations.
Fire/smoke detection systems
63 Safety ratings: Low = No system has been installed; Average = System is partially installed, or infrequently A 1.875
maintained and tested; High = System is installed and well-maintained and tested frequently.
Fire suppression systems (automatic and manual)
64 Safety ratings: Low = No system has been installed; inspections do not occur; Average = System is partially A 1.875
installed, or system is installed, but no maintenance or testing; inspections are incomplete or outdated; High =
System is fully installed and regularly maintained and tested frequently; inspections are complete and up to date.
65 A 1.125
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Safety ratings: Low = A source of permanent supply which could be used for fire suppression does not exist;
65 Average = A source of permanent supply of water is available for fire suppression; there is limited capacity A 1.125
available, and no maintenance and testing has been conducted; High = A source of permanent water supply with
significant capacity for fire suppression is available, regularly maintained and frequently tested.
Safety ratings: Low = Fuel storage is not accessible and is not located in a secure site; Average = Site in fair
condition and in fair location in relation to hazards; some measures provide partial protection; High = In good
74 condition and good location, well-secured and other protection measures in place; fuel tanks are accessible. A 1
Safety ratings: Low = Medical gas tanks and cylinders in storage areas are poor condition; no protection
measures, not secured; personnel are not trained to operate medical gas and fire extinguishing equipment;
78 Average = Medical gas tanks and cylinders in storage areas are in fair condition, some measures provide partial A 1
protection; the quality of anchors and braces is inadequate; personnel are trained to operate equipment; High =
Good condition, well-secured and protected, anchors are of good quality for major hazards; medical gas and fire
extinguishing equipment operated by qualified personnel.
Condition and safety of medical gas distribution system (e.g. valves, pipes, connections)
79 Safety ratings: Low = Less than 60% of the system is in good working condition; Average = Between 60% and A 1
80% of the system is in good working condition; High = More than 80% of the system is in good working
condition.
Condition and safety of medical gas cylinders and related equipment in the hospital
Safety ratings: Low = Medical gas tanks and cylinders in hospital areas are in poor condition, no protective
80 measures; not secured; Average = Medical gas tanks and cylinders are in fair condition; the quality of anchors A 1
and braces is inadequate; some measures provide partial protection; High = Good condition, well-secured and
protected; anchors are of good quality for major hazards.
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Availability of alternative sources of medical gases
81 Safety Ratings: Low = Alternative sources are not available; Average = Alternative sources in place but delivery A 0.75
of supplies takes longer than 15 days; High = Sufficient alternative sources are available at short notice (less
than 15 days).
Emergency maintenance and restoration of medical gas systems
Safety ratings: Low = Documented procedures and maintenance/inspection records do not exist; Average =
82 Documented procedures exist, maintenance/inspection records are up to date, and personnel have been A 0.25
trained, but resources are not available; High = Procedures exist, maintenance/inspection records are up to
date, personnel have been trained, and resources are in place for implementing emergency maintenance and
restoration.
3.3.8 Heating, ventilation, and air-conditioning (HVAC) systems 5.00
Adequate location of enclosures for HVAC equipment
Safety ratings: Low = HVAC enclosures are not accessible and they are not located in a safe site; there are no
83 protective measures; Average = HVAC enclosures are accessible, located at a safe site; some measures provide A 0.75
partial protection from hazards; High = HVAC enclosures are accessible, in a safe location and protected from
hazards.
Safety of enclosures for HVAC equipment
84 Safety ratings: Low = HVAC equipment is not accessible; no protective measures for safe operation and A 1
maintenance; Average = HVAC is accessible; some measures provide partial protection; High = HVAC
equipment is accessible, wide range of protection measures in place.
Safety and operating condition of HVAC equipment (e.g. boiler, exhaust)
Safety ratings: Low = HVAC equipment in poor condition, not maintained; Average = HVAC equipment in fair
85 condition; some measures provide partial protection, but no regular maintenance; High = Good condition, well- A 1
secured and protected from hazards (e.g. anchors are of good quality); regular maintenance and testing of
controls and alarms conducted.
Adequate supports for ducts and review of flexibility of ducts and piping that cross expansion joints
86 A 0.5
Safety ratings: Low = Supports are lacking and connections are rigid; Average = Supports are in fair condition or
connections are flexible; High = Supports are in good condition and connections are flexible.
Condition and safety of pipes, connections and valves
87 Safety ratings: Low = Less than 60% of pipes are in good condition; limited protective measures against A 0.5
hazards; Average = Between 60% and 80% are in good condition; some measures provide partial protection
against hazards; High = Above 80% are in good condition and are well-secured and protected against hazards.
88 Safety ratings: Low = Air-conditioning units in poor condition, not secured; Average = Air-conditioning units are in A 0.5
fair condition; some measures provide partial protection (e.g. quality of anchors and braces is inadequate); High
= Good condition, well-secured and protected from hazards (e.g. anchors are of good quality).
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Condition and safety of equipment and supplies in the sterilization services
99 Safety ratings: Equipment is lacking or in poor condition, or there are no protective measures; Average = A 0.765
Equipment is in fair condition and some measures provide partial protection; High = Equipment is in good
condition, is well-secured and measures provide good protection.
Condition and safety of medical equipment for obstetric emergencies and neonatal care
100 Safety ratings: Low = Equipment is lacking or in poor condition, or there are no protective measures; Average = A 0.306
Equipment is in fair condition and some measures provide partial protection; High = Equipment is in good
condition, is well-secured and measures provide good protection.
Condition and safety of medical equipment and supplies emergency care for burns
101 Safety ratings: Low = Equipment is lacking, is in poor condition, or there are no protective measures; Average = A 0.306
Equipment is in fair condition and some measures provide partial protection; High = Equipment is in good
condition, is well-secured and measures provide good protection.
Condition and safety of medical equipment for nuclear medicine and radiation therapy
Safety ratings: Low = Equipment is lacking, is in poor condition, or there are no protective measures; Average =
Equipment is in fair condition and some measures provide partial protection; High = Equipment is in good
102 condition, is well-secured and measures provide good protection. A 0.306
112 Safety ratings: Low = Committee does not exist, or 1–3 departments or disciplines represented; Average = A 3
Committee exists with 4–5 departments or disciplines represented, but is not fulfilling functions effectively; High
= Committee exists with 6 or more departments or disciplines represented and is fulfilling functions effectively.
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Coordination mechanisms and cooperative arrangements with local emergency/disaster management
agencies
118 A 1.5
Safety ratings: Low = No arrangements exist; Average = Arrangements exist but are not fully operational; High =
Arrangements exist and are fully operational.
Coordination mechanisms and cooperative arrangements with the health-care network
119 Safety ratings: Low = No arrangements exist; Average = Arrangements exist but are not fully operational; High = A 1.5
Arrangements exist and are fully operational.
4.2 Hospital emergency and disaster management response and recovery planning 18.00
Hospital emergency or disaster response plan
120 Safety ratings: Low = Plan is not documented; Average = Documented plan is complete, but is not easily A 6.3
accessible, not up to date (more than 12 months since the last update); High = Plan is complete, easily
accessible, reviewed/updated at least annually, and resources are available to implement the plan.
Hazard-specific subplans
Safety ratings: Low = Hazard-specific response subplans are not documented; Average = Documented plans are
121 complete but not easily accessible, not up to date (more than 12 months since last review/update); High = A 5.4
Documented plans are complete, reviewed/updated at least annually, and resources are available to implement
the plans.
Procedures to activate and deactivate plans
122 Safety ratings: Low = Procedures do not exist or exist only as a document; Average = Procedures exist, A 1.26
personnel have been trained, but procedures are not updated or tested annually; High = Up-to-date procedures
exist, personnel have been trained, and procedures have been tested at least annually.
Hospital emergency and disaster response plan exercises, evaluation and corrective actions
123 Safety ratings: Low = Response plan and subplans have not been tested; Average = Response plan or subplans A 3.6
are tested, but are not tested at least annually; High = Response plan or subplans are tested at least annually
and updated according to the exercise results.
Hospital recovery plan
124 Safety ratings: Low = Recovery plan is not documented; Average = Documented plan is complete but not easily A 1.44
accessible, not up to date (more than 12 months since last review/update); High = Documented plan is
complete, easily accessible, and reviewed/updated at least annually.
4.3 Communication and information management 7.00
Emergency internal and external communication
Safety ratings: Low = Central internal and external communication system functions inconsistently or
125 incompletely; operators are not trained in emergency communication; Average = System functions appropriately, A 2.8
operators have received some training in emergency communication, tests are not conducted at least annually;
High = System functions completely and operators are fully trained in emergency use, and tests of the system
are conducted at least annually.
External stakeholder directory
126 Safety ratings: Low = Directory of external stakeholders does not exist; Average = Directory exists but is not A 1.75
current (more than 3 months since it was updated); High = Directory is available, is up to date and is held by key
emergency response staff.
Procedures for communicating with the public and media
127 Safety ratings: Low = Procedures do not exist, no spokesperson nominated; Average = Procedures exist and A 1.4
nominated spokespersons have been trained; High = Procedures exist, nominated spokespersons have been
trained, and procedures have been tested at least annually.
Management of patient information
128 Safety ratings: Low = Procedures for emergency situations do not exist; Average = Procedures for emergency A 1.05
situations exist and personnel have been trained but no resources are available; High = Procedures for
emergency situations exist, personnel have been trained, and resources are in place for implementation.
138 A 5
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Safety ratings: Low = Procedures do not exist or exist only as a document; Average = Procedures exist,
138 personnel have been trained but would not be available at all times; High = Procedures exist, personnel have A 5
been trained, and resources are available to implement procedures at maximum hospital capacity for emergency
and disaster situations at all times.
Continuity of essential clinical support services
Safety ratings: Low = Procedures do not exist or exist only as a document; Average = Procedures exist and
139 personnel have been trained but would not be available at all times; High = Procedures exist, personnel have A 3.75
been trained, and resources are available to implement procedures at maximum hospital capacity for emergency
and disaster situations at all times.
Expansion of usable space for mass casualty incidents
Safety ratings: Low = Space for expansion has not been identified; Average = Space has been identified;
140 equipment, supplies and procedures are available to carry out the expansion and staff have been trained, but A 2.5
testing has not been conducted; High = Procedures exist and have been tested, personnel have been trained,
and equipment, supplies and other resources are available to carry out the expansion of space.
Triage for major emergencies and disasters
Safety ratings: Low = Designated triage location or procedures do not exist; Average = Triage location and
141 procedures exist and personnel have been trained, but procedures have not been tested for emergency and A 3
disaster situations; High = Location and procedures exist and have been tested, personnel have been trained,
and resources are in place to implement at maximum hospital capacity in emergency and disaster situations.
Triage tags and other logistical supplies for mass casualty incidents
142 Safety ratings: Low = Nonexistent; Average = Supply covers less than 72 hours of maximum hospital capacity; A 0.75
High = Supply guaranteed for at least 72 hours of maximum hospital capacity.
System for referral, transfer and reception of patients
Safety ratings: Low = Procedures do not exist or exist only as a document; Average = Procedures exist and
143 personnel have been trained, but procedures have not been tested for emergency or disaster situations; High = A 2.5
Procedures exist and have been tested, personnel have been trained, and resources are available to implement
measures at maximum hospital capacity in emergency or disaster situations.
Infection surveillance, prevention, and control procedures
Safety ratings: Low = Policies and procedures do not exist; standard precautions for infection prevention and
control are not followed routinely; Average = Policies and procedures exist, standard precautions are routinely
144 followed, personnel have been trained, but the level of resources required for emergency and disaster situations, A 3.75
including epidemics, is not available; High = Policies and procedures exist, infection prevention and control
measures are in place, personnel have been trained, and resources are available to implement measures at
maximum hospital capacity in emergency and disaster situations.
Psychosocial services
Safety ratings: Low = Procedures do not exist or exist only as a document; Average = Procedures exist and
145 personnel have been trained, but the level of resources required for emergency and disaster situations is not A 2.5
available; High = Procedures exist, personnel have been trained, and resources are available for implementation
of procedures at maximum hospital capacity in emergency and disaster situations.
Post-mortem procedures in a mass fatality incident
Safety ratings: Low = Procedures for a mass fatality incident do not exist or exist only as a document; Average =
146 Procedures exist and personnel have been trained, but the level of resources required for emergency and A 1.25
disaster situations is not available; High = Procedures exist, personnel have been trained, and resources are
available for implementation of procedures at maximum hospital capacity in emergency and disaster situations
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Hospital Safety Index: Page 1_Step 1-2 (Safety Ratings)
PLEASE NOTE STEP 2 AT THE END OF THIS TABLE WHICH REQUIRES FOR
TRANSLATION AS FOLLOWS -
Step 2: Before moving on to the next step, ensure that there are no "ERROR".In
case an "ERROR" message is shown, refer back to that specific question and
answer it according to Step 3. Charts and formulas will not calculate properly if
there are any "ERROR" messages.
Step 1: Enter a number "1" in the corresponding YELLOW cell of each item. Some rows would stay in BLANK only if there is a note in CAPITAL LETTERS.
Safety level
2.1 Prior events and hazards affecting building safety Control
Low Average High
1. Prior major structural damage or failure of the hospital building(s)
Safety ratings: Low = Major damage and no repairs; Average = Moderate damage and
building only partially repaired; High = Minor or no damage, or building fully repaired.
OK 1
Safety ratings: Low = Major remodelling or modifications have been carried out with major
compromising effect on the performance of the structure; Average = Moderate remodelling OK 1
and/or modifications with minor effect on the performance of the structure; High = Minor
remodelling and/or modifications; no modifications were carried out; or major remodelling
and/or modification enhancing the structural behaviour or having no negative effect.
Safety level
2.2 Building integrity Control
Low Average High
4. Structural system design
Safety ratings: Low = Poor structural system design; Average = Moderate structural OK 1
system design; High = Good structural system design.
5. Condition of the building
Safety ratings: Low = Cracks on the ground and first floors; Major deterioration caused by OK 1
weathering or normal ageing; Average = Some deterioration caused only by weathering or
normal ageing; High = No deterioration or cracks observed.
6. Condition of the construction materials
Safety ratings: Low = Rust with flaking; cracks larger than 3 mm (concrete), excessive
deformations (steel and wood); Average = Cracks between 1 and 3 mm present OK 1
(concrete), moderate and visible deformations (steel and wood) or rust with no flaking;
High = Cracks less than 1 mm (concrete), no visible deformations; no rust.
Safety ratings: Low = Fewer than three lines of resistance in each direction; Average = OK 1
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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Safety ratings: Low = Strength of beams is obviously greater than strength of columns; OK 1
Average = Strength of beams is similar to strength of columns; High = Strength of
columns is greater than strength of beams.
13. Safety of foundations
Safety ratings: Low = No evidence that foundations were designed according to standards
(foundation size, soil survey) and/or there is evidence of damage; no plans are available;
Average = Little evidence (drawings, soil survey) that foundations were designed OK 1
according to standards; and/or there is evidence for moderate damage; High = Strong
evidence that foundations were designed according to standards with strong evidence of
no damage.
14. Irregularities in building structure plan (rigidity, mass, resistance)
Safety ratings: Low = Shapes are irregular and structure is not uniform; Average = Shapes OK 1
on plan are irregular but structure is uniform; High = Shapes on plan are regular and
structure has uniform plan, and there are no elements that would cause significant torsion.
Safety ratings: Low = Doors, exits and entrances in poor condition, subject to damage
which would impede the function of this and other elements, systems or operations;
entrance width is less than 115 cm; Average = In fair condition, subject to damage but OK 1
damage would not impede the function of this and other elements, systems or operations;
or entrance width is less than 115 cm; High = In good condition, no or minor potential for
damage that would impede the function of this and other elements, systems or operations;
and entrance width is equal to or larger than 115 cm.
Safety ratings: Low = Building envelope in poor condition, subject to damage which would
impede the function of this and other elements, systems or operations; Average = In fair OK 1
condition, subject to damage but damage would not impede the function of this and other
elements, systems or operations; High = In good condition, no or minor potential for
damage that would impede the function of this and other elements, systems or operations.
Safety ratings: Low = Roofing in poor condition, subject to damage which would impede
the function of this and other elements, systems or operations; Average = In fair condition, OK 1
subject to damage but damage to element(s) would not impede function of this and other
elements, systems or operations; High = In good condition, no or minor potential for
damage that would impede the function of this and other elements, systems or operations.
OK 1
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Safety ratings: Low = Railings and parapets in poor condition, subject to damage which
would impede the function of this and other elements, systems or operations; Average = OK 1
Subject to damage but damage to element(s) would not impede the function of this and
other elements, systems or operations; High = No or minor potential for damage that
would impede the function of this and other elements, systems or operations.
Safety ratings: Low = No protection measures taken; subject to damage, failure and
disruption of critical services and hospital operations in emergencies and disasters;
Average = Partial measures to protect critical services from local hazards are taken; OK 1
subject to damage with some disruption of critical services and hospital operations in
emergencies or disasters; High = Many measures are taken to protect critical services;
high probability that critical services and hospital will operate with no or limited disruption
in emergencies and disasters.
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35. Hospital access routes
Safety ratings: Low = Access routes subject to obstacles and damage that would impede
access and the function of other elements, systems or operations; Average = Access OK 1
routes subject to some obstacles and damage that would not impede access and function;
High = No or minor potential for obstacles or damage that would impede access and the
function of other elements, systems or operations.
36. Emergency exits and evacuation routes
Safety ratings: Low = Exit and evacuation routes are not clearly marked and many are OK 1
blocked; Average = Some exit and evacuation routes are marked and most are clear of
obstacles; High = All exit and evacuation routes are clearly marked and free of obstacles.
Safety ratings: Low = Internal and external lighting systems are in poor condition, there OK 1
are no protective measures; Average = In fair condition; some measures provide partial
protection; High = In good condition, well-protected and in good working order.
49. Condition and safety of low- and extra-low-voltage systems (Internet and telephone)
OK 1
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Safety ratings: Low = Low voltage systems in poor condition, there are no protective OK 1
measures; Average = Low voltage systems in fair condition, some measures provide
partial protection; High = Good condition, well-secured and other protection measures in
place.
50. Alternative communication systems
Safety ratings: Low = Alternate communications systems do not exist, are in poor
condition, or do not function; Average = Hospital-wide alternate communications system in OK 1
fair condition, but is not tested on an annual basis; High = Alternate communication
system in good condition and tested at least annually.
51. Condition and safety of telecommunications equipment and cables
Safety ratings: Low = Telecommunications equipment and cables are in poor condition;
there are no protective measures; Average = Equipment and cables are in fair condition; OK 1
some measures provide partial protection; High = In good condition, well-secured and
protected from hazards.
52. Effect of external telecommunications systems on hospital communications
Safety ratings: Low = External telecommunications systems cause major interference with
hospital communications; Average = External telecommunications system cause OK 1
moderate interference with hospital communications; High = External communications
cause no interference with hospital communications.
53. Safety of sites for telecommunication systems
Safety ratings: Low = Sites for telecommunications systems are in poor condition, at high
risk of failure due to hazards; there are no protective measures; Average = Sites in fair OK 1
condition; some measures provide partial protection; High = Good condition, well-secured
and other protective measures in place.
54. Condition and safety of internal communications systems
Safety ratings: Low = Internal communications systems do not exist or are in poor
condition; Average = Internal communications systems are in fair condition, but there are OK 1
no alternate systems; High = Internal communications and back-up systems are in good
working order.
55. Emergency maintenance and restoration of standard and alternate communications
systems
Safety ratings: Low = Documented procedures and maintenance/inspection records do
not exist; Average = Documented procedures exist, maintenance/inspection records are OK 1
up to date, personnel have been trained, but resources are not available; High =
Documented procedures exist, maintenance/inspection records are up to date, personnel
have been trained, and resources are in place for implementing emergency maintenance
and restoration.
3.3.3 Water supply system
56. Water reserves for hospital services and functions
Safety ratings: Low = Sufficient for 24 hours or less, or water tank does not exist; Average OK 1
= Sufficient for more than 24 hours but less than 72 hours; High = Guaranteed to cover at
least 72 hours.
57. Location of water storage tanks
Safety ratings: Low = The site is vulnerable with high risk of failure (e.g. structural,
architectural and/or system vulnerabilities); Average = The site is exposed to moderate
risk of failure (e.g. structural, architectural and/or system vulnerabilities); High = The site is
not exposed to visually identifiable risks (e.g. structural, architectural and/or system OK 1
vulnerabilities).
IF THE HOSPITAL DOES NOT HAVE A WATER STORAGE TANK, LEAVE BOXES
BLANK.
58. Safety of the water distribution system
Safety ratings: Low = Less than 60% are in good operational condition; Average = OK 1
Between 60% and 80% are in good condition; High = Above 80% are in good condition.
Safety ratings: Low = There is no back-up pump and operational capacity does not meet
minimum daily demand; Average = Supplementary pumps are in fair condition but would OK 1
not meet the minimum daily demand for water; High = All supplementary pumps and back-
up systems are operational and would meet the minimum demand for water.
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64. Fire suppression systems (automatic and manual)
Safety ratings: Low = No system has been installed; inspections do not occur; Average =
System is partially installed, or system is installed, but no maintenance or testing; OK 1
inspections are incomplete or outdated; High = System is fully installed and regularly
maintained and tested frequently; inspections are complete and up to date.
65. Water supply for fire suppression
Safety ratings: Low = A source of permanent supply which could be used for fire
suppression does not exist; Average = A source of permanent supply of water is available OK 1
for fire suppression; there is limited capacity available, and no maintenance and testing
has been conducted; High = A source of permanent water supply with significant capacity
for fire suppression is available, regularly maintained and frequently tested.
Safety ratings: Low = Tanks are in poor condition; there are no anchors or tank enclosure;
tanks are not safely located with respect to hazards; Average = Tanks are in fair condition,
anchors and bracing are inadequate for major hazards; tank enclosure has some safety
and security measures; High = Tanks are in good condition; anchors and bracing are in OK 1
good condition for major hazards; the tank enclosure has adequate safety and security.
75. Condition and safety of the fuel distribution system (valves, hoses, and connections)
Safety ratings: Low = Less than 60% of the system is in safe operational condition;
Average = between 60% and 90% of the system is in good operational condition and has
automatic shut-off valves; High = More than 90% of the system is in good operational OK 1
condition and has automatic shut-off valves.
OK 1
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Safety ratings: Low = Documented procedures and maintenance/inspection records do
not exist; Average = Documented procedures exist, maintenance/inspection records are
up to date, personnel have been trained, but resources are not available; High = OK 1
Documented procedures exist, maintenance/inspection records are up to date, personnel
have been trained, and resources are in place for implementing emergency maintenance
and restoration.
Safety ratings: Low = Medical gas tanks and cylinders in storage areas are poor condition;
no protection measures, not secured; personnel are not trained to operate medical gas
and fire extinguishing equipment; Average = Medical gas tanks and cylinders in storage OK 1
areas are in fair condition, some measures provide partial protection; the quality of
anchors and braces is inadequate; personnel are trained to operate equipment; High =
Good condition, well-secured and protected, anchors are of good quality for major
hazards; medical gas and fire extinguishing equipment operated by qualified personnel.
79. Condition and safety of medical gas distribution system (e.g. valves, pipes,
connections)
Safety ratings: Low = Less than 60% of the system is in good working condition; Average OK 1
= Between 60% and 80% of the system is in good working condition; High = More than
80% of the system is in good working condition.
80. Condition and safety of medical gas cylinders and related equipment in the hospital
Safety ratings: Low = Medical gas tanks and cylinders in hospital areas are in poor
condition, no protective measures; not secured; Average = Medical gas tanks and OK 1
cylinders are in fair condition; the quality of anchors and braces is inadequate; some
measures provide partial protection; High = Good condition, well-secured and protected;
anchors are of good quality for major hazards.
81. Availability of alternative sources of medical gases
Safety Ratings: Low = Alternative sources are not available; Average = Alternative OK 1
sources in place but delivery of supplies takes longer than 15 days; High = Sufficient
alternative sources are available at short notice (less than 15 days).
82. Emergency maintenance and restoration of medical gas systems.
Safety ratings: Low = Documented procedures and maintenance/inspection records do
not exist; Average = Documented procedures exist, maintenance/inspection records are
up to date, and personnel have been trained, but resources are not available; High = OK 1
Procedures exist, maintenance/inspection records are up to date, personnel have been
trained, and resources are in place for implementing emergency maintenance and
restoration.
Safety ratings: Low = HVAC enclosures are not accessible and they are not located in a
safe site; there are no protective measures; Average = HVAC enclosures are accessible, OK 1
located at a safe site; some measures provide partial protection from hazards; High =
HVAC enclosures are accessible, in a safe location and protected from hazards.
436910397.xlsx OK 1
Safety ratings: Low = Documented procedures and maintenance/inspection records do
not exist; Average = Documented procedures exist, maintenance/inspection records are
up to date, personnel have been trained, but resources are not available; High = OK 1
Documented procedures exist, maintenance/inspection records are up to date, personnel
have been trained, and resources are in place for implementing emergency maintenance
and restoration.
Safety level
3.4 Equipment and supplies Control
Low Average High
3.4.1 Office and storeroom furnishings and equipment (fixed and movable)
91. Safety of shelving and shelf contents
Safety ratings: Low = Shelving is not safely located (or in seismic and wind-prone areas
not attached to walls in in more than 20% of cases); Average = Shelving is safely located OK 1
(and attached to walls in seismic and wind-prone areas) and contents are secured in
20−80% of cases; High = More than 80% of shelving and the contents of shelves are
safely located, attached to walls, and contents are secured.
92. Safety of computers and printers
Safety ratings: Low = No measures to protect computers from hazards are in place;
Average = Computers are in safe locations, some measures offer partial protection from OK 1
hazards; High = Computers are in safe locations, well-secured and good protective
measures in place.
3.4.2 Medical and laboratory equipment and supplies used for diagnosis and treatment
93. Safety of medical equipment in operating theatres and recovery rooms
Safety ratings: Low = The operating theatres are in an unsafe location, equipment is
lacking or in poor condition or there are no protective measures; Average = The operating OK 1
theatres are in a safe location, equipment is in fair condition, and some measures provide
partial protection; High = Operating theatres are in a safe location, equipment is in good
condition, is well-secured and measures provide protection.
94. Condition and safety of radiology and imaging equipment
Safety ratings: Low = The radiology and imaging equipment is not in a safe location,
equipment is lacking or in poor condition, or there are no protective measures; Average = OK 1
The equipment is in a safe location, is in fair condition, and some measures offer partial
protection; High = Equipment is in a safe location, is in good condition, well-secured and
measures provide good protection.
95. Condition and safety of laboratory equipment and supplies
Safety ratings: Low = Biosafety measures are poor, laboratory equipment is lacking or in
poor condition, or there are no protective measures; Average = Biosafety measures are in OK 1
place, the equipment is in fair condition, and some measures provide partial protection;
High = Biosafety measures in place, equipment is in good condition, well-secured and
measures provide good protection.
96. Condition and safety of medical equipment in emergency care services unit
Safety ratings: Low = The medical equipment is lacking or in poor condition, or there are
no protective measures; Average = The equipment is in fair condition and some measures OK 1
provide partial protection; High = Equipment is in good condition, well-secured and
measures provide good protection.
97. Condition and safety of medical equipment in intensive or intermediate care unit
Safety ratings: Low = The medical equipment is lacking or in poor condition, or there are
no protective measures; Average = The equipment is in fair condition and some measures OK 1
provide partial protection; High = Equipment is in good condition, is well-secured and
measures provide good protection.
98. Condition and safety of equipment and furnishings in the pharmacy
Safety ratings: Low = The equipment in the pharmacy is lacking or in poor condition, or
there are no protective measures; Average = The equipment is in fair condition and some OK 1
measures provide partial protection; High = Equipment is in good condition, is well-
secured and measures provide good protection.
99. Condition and safety of equipment and supplies in the sterilization services
Safety ratings: Equipment is lacking or in poor condition, or there are no protective
measures; Average = Equipment is in fair condition and some measures provide partial OK 1
protection; High = Equipment is in good condition, is well-secured and measures provide
good protection.
100. Condition and safety of medical equipment for obstetric emergencies and neonatal
care
Safety ratings: Low = Equipment is lacking or in poor condition, or there are no protective OK 1
measures; Average = Equipment is in fair condition and some measures provide partial
protection; High = Equipment is in good condition, is well-secured and measures provide
good protection.
101. Condition and safety of medical equipment and supplies emergency care for burns
Safety ratings: Low = Equipment is lacking, is in poor condition, or there are no protective OK 1
measures; Average = Equipment is in fair condition and some measures provide partial
protection; High = Equipment is in good condition, is well-secured and measures provide
good protection.
102. Condition and safety of medical equipment for nuclear medicine and radiation
therapy
Safety ratings: Low = Equipment is lacking, is in poor condition, or there are no protective
measures; Average = Equipment is in fair condition and some measures provide partial
protection; High = Equipment is in good condition, is well-secured and measures provide OK 1
good protection.
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104. Medicines and supplies
Safety ratings: Low = Nonexistent; Average = Supply covers less than 72 hours at OK 1
maximum capacity; High = Supply guaranteed for at least 72 hours at maximum hospital
capacity.
105. Sterilized instruments and other materials
Safety ratings: Low = Nonexistent; Average = Supply cover less than 72 hours at OK 1
maximum capacity; High = Supply is guaranteed for at least 72 hours at maximum
hospital capacity.
106. Medical equipment specifically used in emergencies and disasters
Safety ratings: Low = Nonexistent; Average = Supply covers less than 72 hours at OK 1
maximum hospital capacity; High = Supply guaranteed for at least 72 hours at maximum
hospital capacity.
107. Supply of medical gases
Safety ratings: Low = Less than 10 days’ supply; Average = Supply for between 10 and 15 OK 1
days; High = Supply for at least 15 days.
108. Mechanical volume ventilators
Safety ratings: Low = Nonexistent; Average = Supply covers less than 72 hours at OK 1
maximum hospital capacity; High = Supply guaranteed for at least 72 hours at maximum
hospital capacity.
109. Electromedical equipment
Safety ratings: Low = Nonexistent; Average = Supply covers less than 72 hours at OK 1
maximum hospital capacity; High = Supply guaranteed for at least 72 hours at maximum
hospital capacity.
110. Life-support equipment
Safety ratings: Low = Nonexistent; Average = Supply covers less than 72 hours at OK 1
maximum hospital capacity; High = Supply guaranteed for at least 72 hours at maximum
hospital capacity.
111. Supplies, equipment or crash carts for cardiopulmonary arrest
Safety ratings: Low = Nonexistent; Average = Supplies and equipment for
cardiopulmonary emergencies (or crash carts) in good condition but cover less than 72 OK 1
hours at maximum hospital capacity; High = Supplies and equipment for cardiopulmonary
emergencies (or crash carts) guaranteed in good condition and adequate supplies for at
least 72 hours at maximum hospital capacity.
Safety ratings: Low = There is no staff member who has been assigned responsibilities as
the emergency/disaster management coordinator; Average = Emergency/disaster
management coordination tasks have been assigned to a staff member, but it is not OK 1
his/her main task; High = A staff member is assigned the emergency and disaster
management coordination responsibilities as his/her main task, and is fulfilling the role of
implementing the hospital’s preparedness programme.
115. Preparedness programme for strengthening emergency and disaster response and
recovery
Safety ratings: Low = A programme for strengthening preparedness, response and
recovery does not exist or, if it exists, no preparedness activities are being implemented; OK 1
Average = A programme for strengthening preparedness, response and recovery exists
and some activities are being implemented; High = A programme for strengthening
preparedness, response and recovery is being fully implemented under the leadership of
the Hospital Emergency/Disaster Committee.
116. Hospital incident management system
Safety ratings: Low = No arrangements for hospital incident management exist; Average =
Staff assigned to key hospital incident management positions but with no written OK 1
procedures to operationalize its functions; High = Hospital incident management
procedures exist and are fully operational with properly trained personnel to assume
different coordination roles and responsibilities.
117. Emergency Operations Centre (EOC)
Safety ratings: Low = The EOC is not designated or is in an unsafe or insecure location;
Average = The designated EOC is in a safe, secure and accessible location, but would OK 1
have limited operational capacity immediately in an emergency; High = The EOC is in a
safe, secure and accessible location with immediate operational capacity.
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OK 1
Safety ratings: Low = No arrangements exist; Average = Arrangements exist but are not
fully operational; High = Arrangements exist and are fully operational.
Safety level
4.2 Hospital emergency and disaster management response and recovery planning Control
Low Average High
120. Hospital emergency or disaster response plan
Safety ratings: Low = Plan is not documented; Average = Documented plan is complete,
but is not easily accessible, not up to date (more than 12 months since the last update); OK 1
High = Plan is complete, easily accessible, reviewed/updated at least annually, and
resources are available to implement the plan.
121. Hazard-specific subplans
Safety ratings: Low = Hazard-specific response subplans are not documented; Average =
Documented plans are complete but not easily accessible, not up to date (more than 12 OK 1
months since last review/update); High = Documented plans are complete,
reviewed/updated at least annually, and resources are available to implement the plans.
Safety ratings: Low = Contact list does not exist; Average = List exists, but is not current OK 1
(more than 3 months since it was updated); High = List is available and up to date.
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134. Agreements with local suppliers and vendors for emergencies and disasters
Safety ratings: Low = No arrangements exist; Average = Arrangements exist, but are not OK 1
fully operational; High = Arrangements exist and are fully operational.
135. Transportation during an emergency
Safety ratings: Low = Ambulances and other vehicles and modes of transportation are not
available; Average = Some vehicles are available, but not in sufficient numbers for a major OK 1
emergency or disaster; High = Appropriate vehicles in sufficient numbers are available
during emergencies/disasters.
136. Food and drinking-water during an emergency
Safety ratings: Low = Procedures for food and drinking-water for emergencies are non-
existent; Average = Procedures exist, food and drinking-water is guaranteed for less than OK 1
72 hours; High = Food and drinking-water for emergencies is guaranteed for at least 72
hours.
137. Financial resources for emergencies and disasters
Safety ratings: Low = Emergency budget or mechanism to access emergency funds is not OK 1
in place; Average = Funds are budgeted and mechanisms are available but cover less
than 72 hours; High = Sufficient funds are guaranteed for 72 hours or more.
Safety level
4.6 Patient care and support services Control
Low Average High
138. Continuity of emergency and critical care services
Safety ratings: Low = Procedures do not exist or exist only as a document; Average =
Procedures exist, personnel have been trained but would not be available at all times; OK 1
High = Procedures exist, personnel have been trained, and resources are available to
implement procedures at maximum hospital capacity for emergency and disaster
situations at all times.
139. Continuity of essential clinical support services
Safety ratings: Low = Procedures do not exist or exist only as a document; Average =
Procedures exists and personnel have been trained but would not be available at all OK 1
times; High = Procedures exists, personnel have been trained, and resources are
available to implement procedures at maximum hospital capacity for emergency and
disaster situations at all times.
140. Expansion of usable space for mass casualty incidents
Safety ratings: Low = Space for expansion has not been identified; Average = Space has
been identified; equipment, supplies and procedures are available to carry out the OK 1
expansion and staff have been trained, but testing has not been conducted; High =
Procedures exist and have been tested, personnel have been trained, and equipment,
supplies and other resources are available to carry out the expansion of space.
Safety ratings: Low = Designated triage location or procedures do not exist; Average =
Triage location and procedures exist and personnel have been trained, but procedures OK 1
have not been tested for emergency and disaster situations; High = Location and
procedures exist and have been tested, personnel have been trained, and resources are
in place to implement at maximum hospital capacity in emergency and disaster situations.
142. Triage tags and other logistical supplies for mass casualty incidents
Safety ratings: Low = Nonexistent; Average = Supply covers less than 72 hours of OK 1
maximum hospital capacity; High = Supply guaranteed for at least 72 hours of maximum
hospital capacity.
143. System for referral, transfer and reception of patients
Safety ratings: Low = Procedures do not exist or exist only as a document; Average =
Procedures exist and personnel have been trained, but procedures have not been tested OK 1
for emergency or disaster situations; High = Procedures exist and have been tested,
personnel have been trained, and resources are available to implement measures at
maximum hospital capacity in emergency or disaster situations.
144. Infection surveillance, prevention, and control procedures
Safety ratings: Low = Policies and procedures do not exist; standard precautions for
infection prevention and control are not followed routinely; Average = Policies and
procedures exist, standard precautions are routinely followed, personnel have been
trained, but the level of resources required for emergency and disaster situations, OK 1
including epidemics, is not available; High = Policies and procedures exist, infection
prevention and control measures are in place, personnel have been trained, and
resources are available to implement measures at maximum hospital capacity in
emergency and disaster situations.
OK 1
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Safety ratings: Low = Plan does not exist or exists only as a document; Average = Plan
exists and personnel have been trained in procedures, but tests are not conducted OK 1
regularly; High = Plan exists, personnel have been trained, and evacuation drills are held
at least annually.
148. Decontamination for chemical/biological hazards
Safety ratings: Low = No personal protective equipment is available for immediate use by
hospital staff, or no decontamination area exists; Average = Personal protective
equipment is available for immediate use, decontamination areas are established, staff OK 1
training and drills are not conducted annually; High = Personal protective equipment is
available for immediate use, decontamination areas are established and personnel are
trained and tested at least annually.
149. Personal protection equipment and isolation for infectious diseases and epidemics
Safety ratings: Low = No personal protective equipment is available for immediate use by
hospital staff, or no isolation area exists; Average = Supply is available for immediate use,
but is sufficient for less than 72 hours of maximum hospital capacity, isolation areas are OK 1
established, staff training and testing of procedures are not conducted annually; High =
Supply is guaranteed for at least 72 hours of maximum hospital capacity and alternate
sources are in place for resupply, isolation areas are established, staff training and testing
of procedures are conducted at least annually.
Safety ratings: Low = Emergency security procedures do not exist or exist only as a
document; Average = Documented procedures exist and personnel have been trained in OK 1
emergency security procedures but testing is not conducted at least annually; High =
Personnel are trained and tests of the documented procedures are held at least annually.
Step 2: Before moving on to the next step, ensure that there are no "ERROR".In case an "ERROR" message is shown, refer back to that specific question and answer
it according to Step 3. Charts and formulas will not calculate properly if there are any "ERROR" messages.
436910397.xlsx
NOTE TO REVIEWERS/TRANSLATORS: PLEASE TRANSLATE ONLY THOSE BOXES IN GREEN. OTHER WORDING IS COPIED FROM THE TEXT
436910397.xlsx
436910397.xlsx
Sangat mungkin bahwa rumah sakit akan berfungsi dalam keadaan darurat dan bencana.
Namun, disarankan untuk melanjutkan dengan langkah-langkah untuk meningkatkan
0.66 – 1 A kapasitas tanggap darurat dan penanggulangan bencana dan untuk melaksanakan
langkah-langkah pencegahan dalam jangka menengah dan panjang untuk meningkatkan
tingkat keselamatan jika terjadi keadaan darurat dan bencana.
Step 12: Automatic comparison of overall safety index with base recommendations above.
Overall health facility status: A
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