The Hospital Safety Index (HSI) is an evaluative framework aimed at measuring the probability of hospitals maintaining service continuity during disasters and emergencies through a standardized checklist focused on structural safety, non-structural elements, and functional capacity (Raeisi et al., 2018; Sunindijo et al., 2020). In the literature, HSI is positioned not merely as a single score answering the question “are we ready?”, but as a management tool that makes specific vulnerabilities visible at the item level; thus, it should be integrated into budget prioritization and quality improvement cycles (Goniewicz et al., 2023; Mojtahedi et al., 2021). When utilized on a broad scale through versions adapted for different countries (e.g., Persian applications), this framework also generates national monitoring and comparison capabilities (Ardalan et al., 2016; Heydari et al., 2024).
Theme 1: Measurement Architecture and “Module Logic”
In HSI applications, the checklist is generally reported to consist of around 145–151 items, with results interpreted through categories such as A (high safety), B (moderate, at risk), and C (low, inadequate) (Raeisi et al., 2018; Sughra et al., 2025). This modular structure imposes a critical strategic distinction: while structural safety is often tied to long investment cycles and legislation, quicker gains are possible in non-structural and functional areas. Consequently, in the design of managerial interventions, “quick wins” and “capital-intensive transformations” cannot be treated the same (Ghanbari et al., 2024; Basiri et al., 2024). In practice, this indicates that the statement “HSI score has increased” is only meaningful alongside the sub-module profile; for instance, in an action research study in Susa, some main modules remained at low levels despite an improvement in the overall category (Raeisi et al., 2018).
Theme 2: Cross-Country and Regional Performance Distribution
A national data-based analysis of 421 hospitals in Iran reported an average total score of around 43 out of 100, with no hospitals in the “high safety” class. This serves as a strong example showing that HSI is suitable for monitoring “gradual improvement” at a system level, even when baseline levels are significantly low (Ardalan et al., 2016). In Lima, Peru, the average HSI remaining at 0.36—with most state hospitals in Category C—suggests that in chronic hazards like earthquake risk, the “functionality” debate must be addressed alongside building age and infrastructure fragility (Zegarra et al., 2023). The fact that the majority of Tunisian university hospitals fell into Category B, with very low scores particularly in the emergency management dimension, highlights the determinative role of the “institutional will, resources, and knowledge” triad (Lamine et al., 2022). Conversely, the reporting of two large public hospitals in Pakistan in Category A emphasizes that HSI can capture high performance even in low- and middle-income contexts, though such results must be interpreted by examining which modules are strongest (Sughra et al., 2025). In Indonesia, the picture is heterogeneous: while some studies show an overall Level B (Sunindijo et al., 2020), multi-institutional analyses reveal distinct regional differences, where some provinces reach Level A while North Sumatra remains at Level B, signaling gaps in “local governance and resource capacity” (Lestari et al., 2022a).
Theme 3: Improvement Over Time and Intervention Effect
Trends monitored through repeated measurements in Kermanshah (2016–2022) showed a decrease in hazard risk scores and significant increases in non-structural and functional scores. This aligns with an improvement path consistent with the “learning system logic of HSI,” while structural safety remained relatively stable, confirming the expected investment rigidity (Ghanbari et al., 2024). Similarly, an increase in safety levels in Isfahan between 2017 and 2022, with a rise in the proportion of hospitals reaching high safety levels, supports this effect of “continuity and institutionalization” (Heydari et al., 2024). At the micro-level, HSI can be linked to quality improvement methodologies: FOCUS-PDCA-based action research reported measurable increases in non-structural preparedness scores, demonstrating that HSI can be transformed from an “audit tool” into an “improvement engine” (Basiri et al., 2024). Furthermore, HSI’s ability to capture significant pre-post improvements in “climate-smart” health facility applications offers the opportunity to link disaster preparedness with climate adaptation policies within the same performance framework; however, sustainability remains dependent on local financial and human resource capacity (Lichtveld et al., 2025).
Theme 4: Extending HSI to the Extra-Hospital Care Ecosystem
Applying HSI to Primary Health Care (PHC) centers materializes the concept that “service continuity” begins before the hospital. Indonesian PHC analyses show Category A in some regions and B in others, identifying regional infrastructure, water and fuel storage, organization, and training as decisive factors in disaster resilience (Lestari et al., 2022b). An HSI evaluation of a PHC center in Serbia showed that even a high total score can translate into loss of function during a real event due to weaknesses in critical infrastructure (emergency power, water, telecom), starkly reminding of the importance of item-level reading in the PHC context (Lapcevic et al., 2019). The “all-hazards” checklist experience for primary care in Northern Italy reported structural gaps in interdisciplinary teams, system integration, and awareness regarding H-EDRM integration, supporting the connection of HSI-like tools to institutional learning design (Lamberti-Castronuovo et al., 2024). Findings measuring backup water and power capacity in island contexts reinforce the need to consider HSI’s “critical infrastructure continuity” dimension alongside contextual risks like geographical isolation (Alexakis et al., 2014).
Theme 5: Methodological Fragilities and the Risk of “False Confidence”
One of the most critical weaknesses of the HSI is the evaluator effect: in Mexico, even hospitals that became non-functional after an earthquake did not show low scores in self-assessments, demonstrating that the tool can produce “optimistic bias” and contradict actual field functional loss when used via self-application (Cruz-Vega et al., 2018). Similarly, warnings regarding the subjective interpretation of protocols and the Hawthorne effect in single-facility evaluations remind us that HSI output may represent “compliance at the moment of measurement” rather than “true resilience” (Goniewicz et al., 2023). Comparisons between tools make this risk even more visible: in Iran, a comparison between SARA (an HSI derivative) and KP HVA suggests that approaches failing to sufficiently account for hazard prioritization may exaggerate preparedness and misdirect resource allocation (Shojaei et al., 2024). Therefore, the minimum standard for HSI applications should include external evaluators, evaluator training, scoring calibration, and, if possible, the systematic addition of a hazard-based risk layer (hazard prioritization) to the results; otherwise, a comical but dangerous management illusion of “the score rose, the problem is over” is produced (Cruz-Vega et al., 2018; Shojaei et al., 2024).
Theme 6: The Role of HSI in Decision Support, Prioritization, and Policy Design
When held solely as a “compliance score,” the operational value of HSI remains limited; its highest value emerges when scores are translated into budgets, project portfolios, and program management (Mojtahedi et al., 2021). In the Indonesian context, a TOPSIS-based Hospital Emergency and Disaster Management index proposal seeks to produce a technical answer to the question of “which hospital, which area, in what order” by combining HSI sub-dimensions with multi-criteria decision-making (Mojtahedi et al., 2021). On an African scale, the evaluation of health DRM strategies shows that a significant number of countries do not perform screenings like HSI sufficiently, indicating that measurement is directly related to policy capacity and that the proliferation of HSI requires legislation, financing, and institutional ownership (Olu et al., 2016). In a national emergency department survey in Germany, the persistence of gaps in structural and infrastructural measures despite the existence of plans suggests that HSI can be used as a framework to enforce a policy-level distinction between “is there a plan?” and “is there physical infrastructure to execute the plan?” (Ramshorn-Zimmer et al., 2025).
Conclusion
The existing evidence pool clarifies three powerful uses of HSI:
- Standardizing the vulnerability profile at the facility and system level.
- Monitoring improvement over time.
- Prioritizing the investment and improvement portfolio (Ardalan et al., 2016; Ghanbari et al., 2024; Mojtahedi et al., 2021).
Conversely, the most critical risk is the production of “false confidence” in applications with weak self-assessment and hazard prioritization. This risk necessitates independent evaluation, calibration, and the triangulation of HSI outputs with real-event performance (downtime, service continuity, critical infrastructure resilience) (Cruz-Vega et al., 2018; Shojaei et al., 2024; Lapcevic et al., 2019). In the research agenda, associating HSI scores with health outcomes and service continuity metrics—on an explanatory and predictive rather than causal plane—and combining them with critical infrastructure capacity measurements in PHC and island contexts appears to be a high-impact path for publication and policy influence (Lichtveld et al., 2025; Alexakis et al., 2014; Lamberti-Castronuovo et al., 2024).
References:
Alexakis, L.-C. G., Codreanu, T. A., & Stratton, S. J. (2014). Water and power reserve capacity of health facilities in the Greek Islands. Prehospital and Disaster Medicine, 29(2), 146–150. https://doi.org/10.1017/S1049023X14000077
Almuida, T., & Tosepu, R. (2023). The Hospital Safety Index in Indonesia and Overseas: A review. Bali Medical Journal, 12(2), 43–45.
Ardalan, A., Keleh, M. K., Saberinia, A., Khorasani-Zavareh, D., Khankeh, H., Miadfar, J., Maleknia, S., Mobini, A., & Mehranamin, S. (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
Basiri, A., Farajzadeh, M. A., Belal, M., & Heidaranlu, E. (2024). Improving the non-structural preparedness of the selected hospital based on the FOCUS-PDCA model: Action research. BMC Emergency Medicine, 24(1). https://doi.org/10.1186/s12873-024-01006-w
Cruz-Vega, F., Elizondo-Argueta, S., Sanchez-Echeverria, J. C., & Loria-Castellanos, J. (2018). Hospitals of the Mexican Institute of Social Security in the face of September 2017 earthquakes: Analysis from the perspective of the Safe Hospital Program. Gaceta Médica de México, 154(5), 575–581. https://doi.org/10.24875/GMM.18004348
Djalali, A., Ardalan, A., Ohlen, G., Ingrassia, P. L., Della Corte, F., Castren, M., & Kurland, L. (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
Djalali, A., Castren, M., Khankeh, H., Gryth, D., Radestad, M., Ohlen, G., & Kurland, L. (2013). Hospital disaster preparedness as measured by functional capacity: A comparison between Iran and Sweden. Prehospital and Disaster Medicine, 28(5), 454–461. https://doi.org/10.1017/S1049023X13008807
Ghanbari, V., Hidari, Y., Salari, N., Balikuddembe, J. K., Rahimi, E., & Rostamnia, L. (2024). A longitudinal study of hospital safety from disasters in Kermanshah Province, Iran: Insights for disaster risk reduction. Disaster Medicine and Public Health Preparedness, 18. https://doi.org/10.1017/dmp.2024.67
Goniewicz, M., Khorram-Manesh, A., Timler, D., Al-Wathinani, A. M., & Goniewicz, K. (2023). Hospital disaster preparedness: A comprehensive evaluation using the Hospital Safety Index. Sustainability, 15(17), 13197. https://doi.org/10.3390/su151713197
Heidaranlu, E., Khankeh, H., Ebadi, A., & Ardalan, A. (2017). An evaluation of non-structural vulnerabilities of hospitals involved in the 2012 East Azerbaijan earthquake. Trauma Monthly, 22(2). https://doi.org/10.5812/traumamon.28590
Heydari, F., Meibody, A. A., Ebrahimi, M., Zakeri, R., Marzaleh, M. A., & Bagheri, R. (2024). Hospital safety index: Evaluation of the readiness and safety of hospitals in Isfahan province, Iran. Frontiers in Emergency Medicine, 8(2). https://doi.org/10.18502/fem.v8i2.15459
Lamberti-Castronuovo, A., Lamine, H., Valente, M., Hubloue, I., Barone-Adesi, F., & Ragazzoni, L. (2024). Assessing primary healthcare disaster preparedness: A study in Northern Italy. Primary Health Care Research & Development, 25. https://doi.org/10.1017/S1463423624000124
Lamine, H., Chebili, N., & Zedini, C. (2022). Evaluating the level of disaster preparedness of Tunisian University Hospitals using the Hospital Safety Index: A nationwide cross-sectional study. African Health Sciences, 22(3), 666–673. https://doi.org/10.4314/ahs.v22i3.71
Lapcevic, Z., Mandic-Rajcevic, S., Lepic, M., & Jovanovic, M. (2019). Evaluating a primary healthcare centre’s preparedness for disasters using the Hospital Safety Index: Lessons learned from the 2014 floods in Obrenovac, Serbia. International Journal of Disaster Risk Reduction, 34, 436–442. https://doi.org/10.1016/j.ijdrr.2018.12.014
Lestari, F., Paramitasari, D., Fatmah, Hamid, A. Y., Suparni, EL-Matury, H. J., Wijaya, O., Rahmadani, M., Ismiyati, A., Firdausi, R. A., & Kadir, A. (2022a). Analysis of hospital’s emergency and disaster preparedness using Hospital Safety Index in Indonesia. Sustainability, 14(10), 5879. https://doi.org/10.3390/su14105879
Lestari, F., Paramitasari, D., Kadir, A., Firdausi, N. A., Fatmah, Hamid, A. Y. J., Suparni, O., EL-Matury, H., Wijaya, O., & Ismiyati, A. (2022b). 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
Lichtveld, M., Hospedales, J., Davenport, S. R., Buchanich, J., Harvey, J., Wahid, F. A., & De Freitas, L. (2025). Assessing the effectiveness of climate-smart health facilities in small island Caribbean nations. Annals of Global Health, 91(1). https://doi.org/10.5334/aogh.4755
Luke, J., Franklin, R. C., Dyson, J., & Aitken, P. (2022). Building toward a disaster resilient health system: A study of hospital resilience. Disaster Medicine and Public Health Preparedness, 17. https://doi.org/10.1017/dmp.2022.204
Mishra, K. G., Patnaik, N., Pradhan, N. R., Mohapatra, A., & Saleem, S. M. (2025). Comparative descriptive analysis of hospital disaster preparedness using WHO safety index: A multi-center study from Eastern India. BMC Emergency Medicine, 25(1). https://doi.org/10.1186/s12873-025-01248-2
Mojtahedi, M., Sunindijo, R. Y., Lestari, F., Suparni, & Wijaya, O. (2021). Developing hospital emergency and disaster management index using TOPSIS method. Sustainability, 13(9), 5213. https://doi.org/10.3390/su13095213
Negeri, S. P., & Ramdan, I. M. (2023). Analysis the preparedness of Inche Abdoel Moeis Hospital Samarinda in facing disasters. Bali Medical Journal, 12(2), 7–9.
Olu, O., Usman, A., Manga, L., Anyangwe, S., Kalambay, K., Nsenga, N., Woldetsadik, S., Hampton, C., Nguessan, F., & Benson, A. (2016). Strengthening health disaster risk management in Africa: Multi-sectoral and people-centred approaches are required in the post-Hyogo Framework of Action era. BMC Public Health, 16. https://doi.org/10.1186/s12889-016-3390-5
Raeisi, A. R., Torabipour, A., & Karimi, L. (2018). Evaluating hospital safety index in Susa public hospital: An action research study. Bali Medical Journal, 7(2), 457–461. https://doi.org/10.15562/bmj.v7i2.845
Ramshorn-Zimmer, A., Wurmb, T., Drewitz, K. P., Werdehausen, R., Grashey, R., Achatz, G., Franke, A., Urban, M., Walcher, F., & Brod, T. (2025). Structural resilience and robustness of German hospitals: Results from a nationwide survey of emergency departments. Medizinische Klinik Intensivmedizin und Notfallmedizin. https://doi.org/10.1007/s00063-025-01367-5
Shojaei, F., Sohrabizadeh, S., Qaraeian, P., Khoshsabeghe, H. Y., Jandaghi, J., & Farivar, F. (2024). Comparative analysis of two disaster risk assessment tools for primary health care centers: The case of Iran. International Journal of Disaster Risk Reduction, 107, 104466. https://doi.org/10.1016/j.ijdrr.2024.104466
Singh, P., Sapkota, S., Kc, A., Mahara, L., Achour, N., Ragazzoni, L., & Lamine, H. (2025). Healing after the quake: Evaluating the preparedness of Nepalese hospitals for future disasters. International Journal of Emergency Services, 14(3), 322–334. https://doi.org/10.1108/IJES-04-2025-0019
Sunindijo, R. Y., Lestari, F., & Wijaya, O. (2020). Hospital safety index: Assessing the readiness and resiliency of hospitals in Indonesia. Facilities, 38(1–2), 39–51. https://doi.org/10.1108/F-12-2018-0149
Sughra, U., Riaz, A., Suleman, M., & Imran, M. R. (2025). Evaluating the hospital preparedness for emergencies using WHO Hospital Safety Index Tool. Pakistan Journal of Medical Sciences, 41(3), 676–681. https://doi.org/10.12669/pjms.41.3.10875
Villamil Salcedo, V., & Molina Lopez, A. (2014). General measurements of evacuation of mental patients hospitalized in situations of disasters: Review of the bibliography and suggestions. Salud Mental, 37(5), 365–371.
Zegarra, R. O., Arevalo-Ipanaque, J. M., Sanchez, R. A. A., Martinez, J. A. C., Echevarria, J. C. D., & Gonzalez, P. A. (2023). Disaster preparedness and hospital safety in state hospitals in Lima (Peru). Prehospital and Disaster Medicine, 38(5), 601–605. https://doi.org/10.1017/S1049023X23006179