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Table 3 Indicators of deviation from the standard and intervention in accordance with the standard of functional preparedness in 17 areas of the tool based on the FOCUS-PDCA model

From: Audit of the functional preparedness of the selected military hospital in response to incidents and disasters: participatory action research

Domain

Standard deviations

Interventions based on FOCUS-PDCA model and standard functional preparedness

Command & control

- making supervisors prepared for commanding incidents in non-working hours.

- Lack of active internet and computer equipment in EOC of the hospital

- Lack of important information about operations in disasters in EOC

- Resources were supplied by the hospital’s head

- The risk management committee conducted training sessions for supervisors.

- The risk management committee provided active internet and computer in EOC

- EOC was equipped to:

Important maps

Essential contact list

Operational team lists

Personnel recalling process

Risk assessment

- Recognition of hazards based on their likelihood

- Categorization of likelihood of hazards (high, moderate and poor likelihood)

- Prediction of intensity of each hazard and identification of probable injuries

Early warning system

- Emergency response plan to hazards

- Informing of the occurrence of hazards

- A plan was developed and resources were supplied.

- Training was provided.

- A plan was developed, which included some correct distribution indices.

- People at risk were informed.

- Personnel realize alarms and warnings.

- Warnings are clear, practical with proper information for a proper response.

Surge Capacity-

- Lack of a plan to increase capacity for additional personnel

- Lack of a plan for creating master station in each ward for emergencies

- Lack of development of service prioritization process

- Lack of a plan to provide temporary hospital facilities, meet various needs of survivors in disasters

- A plan was developed and trained.

- The plan was assessed in different exercises (operational & tabletop)

- A plan was developed to create a master station (at least one room) in each ward for emergencies

- It was trained how to direct patients and personnel to these spaces.

- Unnecessary services such as some surgical wards and elective surgeries were cancelled.

- The process owner implemented a tabletop exercise to prioritize services.

- A plan was developed for providing temporary hospital facilities and an on-call program for physicians, nurses, practical nurses and housekeeping aides.

Continuity of function

- Lack of a plan to monitor readiness of hospital powerhouse in emergencies

- Lack of a plan to monitor fire extinction & detection system in some parts of hospital in emergencies

- Adjusting and updating checklist regarding contact numbers of fuel supply centers, maintenance & repair companies of hospital installations

- A plan for producing dual fuel system in hospital

- A plan to create fire detection system in CSR, laundry, dining area of the hospital

Hospital incident command system

- No substitute for public information office and safety officer in HICS chart

- A substitute for public information officer and safety officer was determined.

Safety

- Lack of a plan to safely evacuate and restart the hospital’s laboratory

- Lack of a plan to safely evacuate and restart the hospital’s radiology department

- Lack of a plan to safely evacuate and restart the hospital’s operating room

- A plan was developed to evacuate safely and restart the hospital’s laboratory.

- A plan was developed to safely evacuate and restart the hospital’s radiology department

- A plan was developed to evacuate safely and restart the operating room of the hospital

Security

- Lack of a plan to inform hospital staff and clients of access restrictions.

- Lack of a plan to control crowded areas and parking lots of the hospital.

- Lack of a plan to control overcrowding in the hospital.

- A plan was developed to inform the change of route of employees and clients and vehicles at the time of incidents.

- Signs were installed inside and outside the hospital indicating that the doors would not open or where new entrances were located.

- A program was developed to control crowded areas and parking lots in the hospital.

- A program was developed to control the crowds of patients referred to the hospital.

Communication

- Lack of a plan to document communications in an emergency

- Lack of a plan for communications outside the hospital

- Telephone call recording system application was launched.

- Forms were provided to set up minutes.

- An individual was designated as a spokesperson to coordinate all hospital communications with the community, media and health authorities.

- The spokesperson was trained on security issues due to the military nature of the hospital.

Triage

- Not appointing an experienced person to supervise all stages of triage

- Determining the entry and exit routes to/from the triage

- An emergency physician was appointed to supervise the triage process.

- A general surgeon was appointed as the first substitute in the triage.

- In the absence of an emergency physician or general surgeon in triage, the emergency clerk will be responsible for supervising the triage process.

- Specific entry and exit routes and necessary training were given to the process owners (nurses, ambulance drivers, assistant nurses, security guards, porters, etc.)

Safe evacuation of the hospital

- Lack of a plan regarding signs in emergencies

- Lack of a plan for elevators in an emergency

- Lack of a plan for horizontal evacuation in an emergency

- Lack of a plan for vertical evacuation in an emergency

- Maps of floors were installed in each floor.

- Maps clearly show the emergency exits of the building.

- The route of the emergency staircase is clearly shown.

- Familiar and clear terms are used in the maps to find the emergency exits.

- Instructions for using the elevator in case of fire or emergency evacuation were inserted inside and on the elevators

- Signs were installed for the emergency exit stairway.

- The horizontal evacuation plan of the hospital was developed and trained, meaning that everyone in each department had to move to the opposite side of the danger.

- The vertical evacuation plan of the hospital was developed:

- This refers to the complete evacuation of a floor.

- If the exact location of incident was specified, staff would be relocated to another location in the building where safety has been determined (at least two floors below the incident site).

In the event of a complete evacuation of a structure, staff must be relocated to a safe area outside the building.

Dead bodies

- Lack of a plan to make a temporary mortuary in an emergency

- Lack of a plan on how to discharge the deceased from the mortuary in an emergency

- A plan was developed to make a temporary mortuary with 4 parts (reception room, corpse viewing room, a place for keeping corpses that are not suitable for examination and a room for archiving files and personal belongings).

- Discharge of the deceased from the mortuary in an emergency includes:

- The documents requested for the discharge of dead bodies.

- The person to whom the deceased should be delivered legally.

- Legal confirmation of death, preparation of official death report and return of belongings to people close to the deceased.

Financial/support management/ agreements

- Lack of a plan to identify disasters team members based on tasks assigned in an emergency

- Lack of a plan to provide public liability insurance in case of emergency

• Lack of a plan to conclude an agreement with public hospitals in case of emergency

Lack of a plan to conclude an agreement with military hospitals in an emergency

- Lack of a plan to conclude an agreement with equipment and pharmaceutical companies in case of emergency

- Lack of a plan for tabletop exercise under the supervision of the incident and disaster committee in the hospital, according to the program notified by the Ministry of Health

- Covers were prepared based on the division of the various positions of the disaster committee chart (commander, senior officers, operations, planning, finance and support).

- The color of the covers indicates the type of task assigned.

- A plan was developed to access the covers in the first hour of the incident.

- An initial plan was developed in order to provide public liability insurance in case of emergency.

- An initial plan was developed to conclude an agreement with public hospitals in an emergency

- An initial plan was developed to conclude an agreement with military hospitals in an emergency

- An initial plan was developed to conclude an agreement with equipment and pharmaceutical companies in case of emergency.

Roundtable training program was developed for senior managers.

Human resource

- Lack of a plan to train personnel to play their role in the face of disasters

- Lack of a plan to take care of staff’s families (children, patients, older adults and disabled members) in an emergency

- Lack of a plan for employment of support staff and volunteers at the time of the incident.

- Lack of a plan to complete the personnel injury form and follow up reports in an emergency

- The plan of prioritization and needs assessment of educational priorities was developed.

- An initial plan was developed to hold related training classes in the next 6 months.

- As staff were working longer hours, an initial plan was developed to take care of the staff’s families (children, patients, older adults and disabled members).

- Necessary communications were established to allocate the required spaces to this plan.

- An initial plan was developed to describe the duties and how to use the volunteers.

- An initial plan was developed to ensure the basic needs of volunteers in an emergency (resting place, food, etc.) for at least 72 h.

- The process of temporary liability insurance was developed for volunteers.

- The process of completing the personnel injury form and following up reports was developed.

Epidemiology

• Lack of a plan to replace the hospital’s food cold storage in case of emergency.

-Failure to implement a plan to control the drinking water of the hospital in an emergency

- Lack of a plan to replace the hospital wastewater treatment system in case of damage

- Lack of a plan for regular chlorination of drinking water and accurate recording of chlorine in the water in disasters

- Lack of a plan to replace the hospital waste incinerator system in the event of damage in an emergency.

- Lack of a plan for continuation of hospital laundry in case of damage in an emergency.

- Lack of a plan for continuation of hospital CSR in case of damage in an emergency

• In case of damage to the hospital food cold storage, an alternative plan was developed.

- A plan was developed, trained, exercised and revised to control the drinking water of the hospital and the water storage tanks were supplied in case of damage.

- A plan was developed to replace the hospital wastewater treatment system.

- A plan was developed for regular chlorination of drinking water and recording of the exact amount of chlorine in the water.

- A plan was developed to replace the hospital incinerator system.

- A plan was developed to continue the hospital laundry in case of damage in an emergency,

- A plan was developed to continue the hospital CSR in case of damage in emergency situations,

Post-disaster recovery

- Lack of psychological support teams to respond to incidents and disasters

- Lack of mental health support program for staff and their families in the short and long term in emergencies.

- Lack of a mental health support program for the injured and their families in the short and long term in emergencies.

- Lack of a plan for job description of volunteers in the recovery phase in case of emergency.

- An initial plan was developed to form psychological support teams to respond to incidents and disasters.

- According to the standard, teams consisting of social workers, psychological counselors and clergymen were defined in the initial plan.

- An initial plan was developed to support mental health of staff and their families in short-term courses with the presence of mental health counselors.

- An initial plan was developed to support the mental health of the injured and their families in short-term courses with the presence of mental health counselors.

- An initial plan was developed for job description of volunteers in the recovery phase.

Cultural considerations

- Lack of evaluation plan regarding provision of healthcare services based on religious norms in case of emergency

- Lack of a plan to create a space for the religious duties of the injured, their companions and staff (taking into account the religious norms) in case of emergency.

- Lack of plan for welcoming VIPs in case of emergency

- Lack of a plan to engage clergymen in disasters phases in emergencies.

- An evaluation checklist was prepared to provide healthcare services based on religious norms in case of emergency.

- An initial plan was developed to create a space for the religious duties of the injured, their companions and staff (taking into account the religious norms) in an emergency.

- An initial plan was developed for welcoming VIPs in case of emergency.

Description:

According to the readiness standard, VIP refers to high-ranking government officials, influential and well-known people in the community, so senior hospital managers are obliged to accompany them when visiting the injured and the losses imposed on the hospital.

Evaluators were advised to be careful in this regard because Iranian officials have a great desire to be shown on the media, and therefore disaster commanders and efficient forces spend much time reporting to VIPs. Therefore, it is important to have a previous plan to coordinate with VIPs.

- In collaboration with the hospital’s doctrinal unit, an initial plan was developed to engage clergymen in disasters

Description:

* Religious scholars and clergymen are skillful in spiritual matters and can motivate personnel to be prepared in the preparation phase. They spiritually accelerate the return of injured to their daily activities in the recovery phase.