In brief: The Hospital Safety Index (HSI) is a checklist-based tool from WHO and the Pan American Health Organization (PAHO) that estimates how likely a hospital is to keep functioning during and after an emergency or disaster. It rates structural safety, non-structural safety and emergency and disaster management capacity, and places the hospital in safety category A (0.66 to 1), B (0.36 to 0.65) or C (0 to 0.35).
The Hospital Safety Index: a general introduction
Hospitals are needed most at exactly the moment when earthquakes, floods, storms, fires or epidemics are most likely to damage them. A hospital that collapses or loses power, water or staff in the first hours of a disaster turns from a place of rescue into a second emergency. The HSI was created to answer a practical question before that happens: if a disaster struck today, would this hospital still work?
PAHO and WHO first released the HSI in 2008 as part of the Safe Hospitals Initiative. Growing use outside the Americas led to a revised second edition in 2015 designed as a truly global, all-hazards tool, with new sections on the availability and training of the health workforce and on the security of facilities, staff and patients (WHO & PAHO, 2015). The tool can be applied to a single hospital or to every hospital in a network or region, which makes it useful for comparing facilities and deciding where investment is needed.
What the HSI looks at
| Part of the checklist | What evaluators examine |
|---|---|
| Hazards and the hospital’s role | The hazards the site is exposed to and the hospital’s place in the local emergency network; this sets the context for interpreting the score |
| Structural safety | The building’s load-bearing elements, its history of damage in previous events, and the type and condition of construction |
| Non-structural safety | Critical systems and contents: electrical power, water, medical gases, heating and ventilation, medical and laboratory equipment, architectural elements, access and circulation |
| Emergency and disaster management | Coordination structures, response and recovery plans, communication, human resources, logistics, and plans for surge and continuity of essential services |
How the score is built
Each checklist item is rated as low, average or high safety, item scores are weighted within each module, and the modules are combined into a single index between 0 and 1. In many published applications structural safety carries 50%, non-structural safety 30% and emergency and disaster management 20% of the total weight (for example, the Farsi adaptation used in Iran). The final index is interpreted as follows (Djalali et al., 2014; Lestari et al., 2022):
| Category | Safety index | Interpretation |
|---|---|---|
| A | 0.66 to 1 | The hospital is likely to remain functioning in a disaster; preventive measures are still recommended in the medium and long term |
| B | 0.36 to 0.65 | The hospital may withstand an event, but equipment and critical services are at risk; intervention is needed in the short term |
| C | 0 to 0.35 | The lives and safety of patients and staff are at risk during and after a disaster; urgent intervention is needed |
A version for small and medium-sized health facilities is used to assess primary care centres, reflecting the idea that service continuity starts before the hospital door.
Strengths and limits
- Strengths: rapid, relatively low cost, standardised across countries, and explicitly designed to identify low-cost, high-impact improvements (WHO & PAHO, 2015). National programmes can build on it; Iran, for example, integrated its adapted index into the national health information system and hospital accreditation standards (Ardalan et al., 2016).
- Limits: the guide itself describes a rapid application as an “out-of-focus snapshot” of the hospital. Results depend on evaluator training, and self-assessments can be optimistic, as the review of the HSI research literature on this site shows. A single total score can hide a weak module, so results should always be read module by module and item by item.
How managers can use it
- Form a trained, multidisciplinary evaluator team (engineering, architecture, clinical, emergency management) and, where possible, include external evaluators.
- Separate “quick wins” in non-structural safety and emergency management, such as anchoring equipment or testing generators, from structural measures that need capital investment and long timelines.
- Turn the item-level findings into a costed action plan with owners and dates, and repeat the evaluation to monitor progress.
- Compare the score with real-event performance, such as downtime and service continuity, after drills or actual emergencies.
Where the HSI comes from: the Safe Hospitals movement
Hospitals are expensive to lose. WHO notes that hospitals can absorb up to 70% of ministry of health budgets (World Health Organization [WHO], 2015a), and that in large earthquakes or floods some countries have lost half of their hospital capacity at once (WHO, 2015b). The HSI is the measurement arm of a wider effort to prevent this:
- 2009: World Health Day takes the theme “Save lives, make hospitals safe in emergencies”.
- March 2015: the Sendai Framework for Disaster Risk Reduction 2015–2030, adopted by 187 countries, makes the safety of health facilities a global commitment. WHO releases the Comprehensive Safe Hospital Framework and the second edition of the HSI. By then 79 countries had taken action to make hospitals safer, with more than 3,500 facilities assessed (WHO, 2015b).
- 2015 to 2016: WHO Europe assesses 118 hospitals in seven countries; the Republic of Moldova assesses all 64 public hospitals and builds the HSI criteria into its hospital accreditation process (WHO Regional Office for Europe, n.d.).
- 2017 onwards: PAHO’s Smart Hospitals Toolkit combines the HSI with a Green Checklist and a Baseline Assessment Tool, under the formula “safe + green = smart”, later extended to “safe + green + maintained = smart” (Pan American Health Organization [PAHO], 2017, n.d.).
Related tools and how they differ
| Tool | Focus | Use it when |
|---|---|---|
| Hospital Safety Index (WHO and PAHO, 2nd ed., 2015) | Structural, non-structural and emergency management safety of a hospital | You need a standard, comparable score and an item-level improvement list |
| HSI for small and medium health facilities | Primary care centres and smaller facilities | You assess service continuity outside hospitals |
| Comprehensive Safe Hospital Framework (WHO, 2015) | Policy and programme actions for safe health facilities | You design a national or regional safe hospitals programme |
| Smart Hospitals Toolkit and Green Checklist (PAHO, 2017) | Disaster safety plus environmental performance, with cost-benefit analysis | You want to link resilience with climate adaptation and energy efficiency |
Lessons from the 2023 earthquakes in Türkiye
The Kahramanmaraş earthquakes of 6 February 2023, of magnitude 7.8 and 7.5, tested hospital safety on a scale rarely seen. A rapid field survey of 12 hospitals in seven heavily affected provinces, five base-isolated and seven fixed-base, found that most had been shaken harder than their design levels. Base-isolated buildings with friction pendulum bearings generally met the immediate occupancy goal and better protected non-structural elements, while reinforced concrete fixed-base hospitals built after 2001 avoided collapse and many stayed operational (Qu et al., 2023). Türkiye had prepared for this: a Ministry of Health circular issued in 2013 and updated in 2018 requires hospitals above a certain bed capacity in earthquake zones to be built with seismic isolation, and Adana, Isparta and Istanbul Başakşehir Çam and Sakura city hospitals are among the largest base-isolated buildings in the world (Republic of Türkiye Ministry of Environment, Urbanisation and Climate Change, n.d.).
Engineers also pointed out that for hospitals, collapse is not usually the biggest problem; loss of power and water, and non-structural damage in buildings that stay standing, are (Turner, 2023). This is exactly the distinction the HSI makes. Base isolation protects the frame, but generators, water storage, medical gases, anchored equipment, communication and staff plans decide whether the hospital keeps working, so the structural module should always be read together with the non-structural and emergency management modules.
Related reading on this site: the article summary Hospital Safety Index (HSI), Healthcare Worker Experiences in Türkiye Earthquake Response, The Safety Case: An Introduction (101) and the Risk Management in Healthcare Institutions collection.
Sources for this introduction
- Ardalan, A., Kandi Keleh, M., Saberinia, A., et al. (2016). 2015 estimation of hospitals safety from disasters in I.R. Iran: The results from the assessment of 421 hospitals. PLOS ONE, 11(9), e0161542. https://doi.org/10.1371/journal.pone.0161542
- Djalali, A., Ardalan, A., Ohlen, G., et al. (2014). Nonstructural safety of hospitals for disasters: A comparison between two capital cities. Disaster Medicine and Public Health Preparedness, 8(2), 179–184. https://doi.org/10.1017/dmp.2014.21
- Lestari, F., Paramitasari, D., Kadir, A., et al. (2022). The application of Hospital Safety Index for analyzing primary healthcare center (PHC) disaster and emergency preparedness. Sustainability, 14(3), 1488. https://doi.org/10.3390/su14031488
- Pan American Health Organization. (2017). Smart hospitals toolkit. PAHO. https://www.who.int/publications/m/item/smart-hospitals-toolkit
- Pan American Health Organization. (n.d.). Smart hospitals. https://www.paho.org/en/smarthospitals
- Qu, Z., et al. (2023). Rapid report of seismic damage to hospitals in the 2023 Turkey earthquake sequences. Earthquake Research Advances, 3(4), 100234. https://doi.org/10.1016/j.eqrea.2023.100234
- Republic of Türkiye Ministry of Environment, Urbanisation and Climate Change. (n.d.). Seismic isolation in earthquake-resistant structural design for resilient cities. Çevre Şehir İklim, 4. https://webdosya.csb.gov.tr/db/cis/csidergisi/csisayieng4/files/basic-html/page120.html
- Turner, A. (2023). After the earthquakes: Experts discuss building codes in Türkiye and the U.S. Temblor, via PreventionWeb. https://www.preventionweb.net/news/after-earthquakes-experts-discuss-building-codes-turkiye-and-us
- WHO Regional Office for Europe. (n.d.). WHO/Europe strengthens resilience of hospitals during and after emergencies. ReliefWeb. https://reliefweb.int/report/world/whoeurope-strengthens-resilience-hospitals-during-and-after-emergencies
- World Health Organization & Pan American Health Organization. (2015). Hospital safety index: Guide for evaluators (2nd ed.). WHO. https://www.who.int/publications/i/item/9789241548984
- World Health Organization. (2015a). Comprehensive safe hospital framework. WHO. https://www.who.int/publications/m/item/comprehensive-safe-hospital-framework
- World Health Organization. (2015b, March 15). People’s health at the centre of new global blueprint to reduce disaster risks. https://www.who.int/news/item/15-03-2015-people-s-health-at-the-centre-of-new-global-blueprint-to-reduce-disaster-risks
Cite this page (APA 7)
Kurutkan, M. N. (2026, November 15). Hospital Safety Index: An Introduction (101). The Health Topics. https://healthtopic.org/topics/hospital-safety-index-an-introduction-101/