Factor 1

Among the 3 factors, F1 was found to be the core component factor for evaluating HDP. F1 is characterized by variables from 4 domains—education and training of staff on disaster, monitoring and assessing HDP, hospital disaster plan, and command and control. The combination of the 4 domains is reasonable as the framework comprises essential ingredients for a hospital’s preparedness for disasters. The 4 domains are greatly interrelated to the extent that 1 domain could possibly encapsulate the other 3 domains. Disaster education is an important component of disaster management and usually pursues 2 goals—prevention and mitigation. These include improved outcome for victims and enhanced safety for responders. Adequate disaster education contains, at least, guidelines and a basic training format with a component for evaluation of its effectiveness. ^{Reference Born, Briggs and Ciraulo36} Also, well-trained and equipped personnel are vital elements of disaster response, and training presented in various types (classroom-based courses, e-learning, and drills) requires a standardized and evidence-based approach. ³⁷

The command-and-control domain of F1 is a well-known organizational tool structured around several key principles: early implementation, modular makeup (which allows for expansion or contraction), and standardized terminology. ³⁸ This domain uses a unified incident command system to ultimately develop, examine, and improve decision making and response capacity among hospitals. During emergencies, hospitals are required to identify and command various sectors and organize all available resources to respond effectively within a short period. This domain ensures several levels of command, including security and technical personal as well as medical team, all of whom must be available immediately when an incident arises. This level of command identifies the problem and initiates an appropriate emergency procedure. A second level serves as the next level when an incident is beyond the control of the first level. The second level contains at least 2 staff-level personnel: 1 medical hospital incident manager, who ensures the provision of appropriate incident medical care, and a hospital incident manager (non-medical), whose primary focus is on preserving hospital functionality and providing the medical hospital incident manager with necessary logistic and personnel support. The F1, which shows the rudimentary disaster management system, suggests the use of creative strategies to improve the operational functions of hospitals.

The findings of the current study are not a complete departure from previous studies, which used various tools to assess HDP. ^{Reference Al Khalaileh, Bond and Alasad17–Reference Hammad, Arbon, Gebbie and Hutton26} In KSA, the TJC or Saudi Central Board for Accreditation of Healthcare Institutions requires all hospitals to have written disaster plans and conduct drills on regular basis to assess hospitals’ readiness for disaster situations. ^{Reference Bin Shalhoub, Khan and Alaska39,Reference Bajow and Alkhalil40} In the present study, the hospital disaster plan was identified as one of the most important domains in assessment of HDP. Shalhoub et al. made similar observations in a recent study conducted in Riyadh, which found that all 13 hospitals had disaster plans that mostly covered both internal and external disaster plans, as well as disaster preparedness committee. ^{Reference Merin, Miskin and Lin41} While education and training remain a critical component of F1, an indication that it is an important predictor of HDP, previous studies measuring preparedness among hospitals have had mixed levels of readiness. ^{Reference Merin, Miskin and Lin41,Reference Al-Shareef, Alsulimani and Bojan42}

Factor 2

F2 was a second highly weighted factor and relates with surge capacity, triage, post-disaster recovery, and communication. Triage remains an important component of daily emergency care and disaster management. ^{11,12,34,Reference Hsu, Thomas and Bass35,Reference Koka, Sawe and Mbaya43} Given that F2 is a highly weighted factor, it is conventional that hospitals in previous studies have triage areas available. Hospitals have triage guidelines/protocols, dedicated forms for triage, and nearly all providers involved in triage had received training while a significant proportion of hospitals have a triage area designated for receiving mass casualties during disasters. ^{Reference Mahdaviazad and Abdolahifar18,34,Reference Hsu, Thomas and Bass35,Reference Higgins, Wainright, Lu and Carrico44} However, only up to one-third of providers involved in triaging had received training in another study. ^{Reference Kaji and Lewis45} The use of validated triage protocols and training ensures that effective care and appropriate resource utilization are delivered during disasters.

A critical indicator for measuring HDP is surge capacity, as the WHO recommends enhanced capacities of hospitals to respond adequately to disasters. ^11,12 One of the domains driving F2 is surge capacity. Hospitals are recommended to develop adequate surge capacity by increasing the inpatient spaces, opening up unused areas, canceling elective surgeries, and using alternative areas for extra critical care space. While surge capacity is an important driver of HDP, previous studies have often fallen short of this recommendation with mostly less than half of participating hospitals meeting standards. ^{Reference Mahdaviazad and Abdolahifar18,Reference Maleki and Shojaie46,Reference Dobalian, Stein and Radcliff47} A possible explanation for very low surge capacity could be attributed to the use of different tools for assessment of this particular domain—thus, calling for a standardized comprehensive framework for measuring HDP.

Post-disaster recovery is another domain making up the F2. It is one of the key concepts recommended by the WHO ^11,12 and remains an important path to full recovery to routine clinical care and readiness for future disasters. In this domain, hospitals should have organized meetings to lessons drawn from disaster responses. Recognition for service provision by staff of hospitals, volunteers, and other personnel is critical to motivating many after response to disasters. Little or no information has been found about previous studies using various frameworks that have looked at post-disaster recovery. Taken together, hospitals need to improve capacity in post-disaster recovery, as F2 is highly weighted in terms of HDP assessment.

Factor 3

The third factor represents the domain of safety and security as well as logistics, equipment, and supplies, which draws attention to hospital safety and disaster resources. Handling disasters without sufficient equipment, logistic services, and a regular supply of consumables could be detrimental to human lives as disasters are usually characterized by either physical or internal injuries. Recent studies have shown that most hospitals have adequate equipment and logistic services capacity, though some weaknesses have been reported. ^{Reference Mahdaviazad and Abdolahifar18,Reference Hsu, Thomas and Bass35,Reference Kaji and Lewis45,Reference Der-Martirosian, Radcliff and Gable48}

Safety and security for staff are also necessary to enable care for patients during disasters, ^11,12 and it is not surprising that this domain is a key component of F3. Measurements of safety and security among responding hospitals in previous studies have been mixed. ^{Reference Hsu, Thomas and Bass35,Reference Higgins, Wainright, Lu and Carrico44,Reference Kaji and Lewis45} It is therefore necessary that capacity is built in order to sufficiently respond to disasters whenever they occur. It is reassuring to note that tools for assessment were effective at identifying this domain in F3. Taken together, safety and security for staff have been identified as a key driver to hospitals’ preparedness to disasters and so this area requires enhancement in order to handle disasters when they occur.

Limitations

This study has several limitations. First, the PCA to identify the factors influencing HDP was conducted on a fairly small sample (n = 63) of hospitals in a single region of KSA and may limit the findings from being generalizable to the entire Kingdom or other countries. The current work can be considered as exploratory and thus it is appropriate to validate the identified structure in another region or province, prior to rolling it out in a larger study. We propose that this structure be adopted by health care facilities in other areas or regions for further validation. Second, the present study is a cross-sectional one evaluating data requested from the hospital representatives. While attempts were made to review disaster plans during evaluation, our data are self-reported and are subject to reporting bias. There is also the possibility of an overestimation of positive responses, as respondents may have been concerned that investigators were conducting an official assessment for competency. Finally, the factors or indicators were adopted from the WHO checklist and selected based on a preliminary survey on the most important aspects of disaster preparedness in the study area. As such, mission-critical systems deemed important for continuity of operations were not selected, and thus indicators may not be applicable in all countries and thus limits its generalizability. Notwithstanding the limitations, the identified factors may serve as a checklist to assess the fundamental drivers of HDP and to further identify practices that could be prioritized to ensure that institutions are better prepared for future disasters.