What is "hospital resilience"? A scoping review on conceptualization, operationalization, and evaluation

Exploring influential components and indicators in hospital resilience assessment: a scoping review protocol

INTRODUCTION

Hospitals are vital infrastructures that provide health services during emergencies and disasters. However, in recent years, disasters have led to hospital losses and interruptions in medical services. Consequently, the concept of resilience has garnered significant attention. Despite extensive research, the lack of clarity in explaining hospital resilience poses challenges in effective assessment and identifying key priorities for enhancing disaster risk management. Recently, the WHO's Eastern Mediterranean Regional Office (EMRO) introduced a conceptual framework for the conceptualisation of hospital resilience, defining it through six interconnected components and four resilience capacities. Identifying specific indicators and characteristics for hospital resilience components based on the EMRO framework. This protocol outlines the method for conducting a scoping review to identify such indicators and characteristics to develop a comprehensive hospital resilience assessment tool.

METHODS AND ANALYSIS

This scoping review will adhere to the six-step protocol proposed by Arksey and O'Malley. It aims to comprehensively understand current knowledge about resilient hospital characteristics and identify effective components and indicators for assessing hospital resilience. The review will encompass available articles indexed in PubMed, Scopus and Web of Science. Additionally, searches will explore the grey literature on Google Scholar, the WHO's website and regional offices. There will be no publication date restrictions applied to the search. Quantitative and qualitative content analyses will assess and categorise the study results. Our protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols extension for scoping reviews.

ETHICS AND DISSEMINATION

This protocol describes a scoping review within a doctoral thesis focused on health in emergencies and disasters, specifically hospital resilience. The study, associated with ethics code number (IR.USWR.REC.1402.120), aims to develop a comprehensive assessment tool for hospital resilience. Once peer-reviewed and published, the findings will inform experts, policymakers and relevant organisations in emergency and disaster management.

Resilience of hospitals in an age of disruptions: a systematic literature review on resources and capabilities

Hospitals play a critical role in ensuring continuous and effective healthcare delivery, especially during crises. However, the COVID-19 pandemic exposed vulnerabilities in hospital systems, prompting a need to enhance resilience-the ability to withstand, absorb, respond to, recover from, and learn from disasters. A systematic literature review, grounded in the resource-based view, identified organizational characteristics, in terms of resources and capabilities, and their synergistic effects that bolster hospital resilience. The results demonstrate that digital technologies impact on anticipation and adaptation abilities, organizational capabilities to reorganize roles, tasks, and spaces enhance adaptability, and Inter-organizational collaborations increase the responsiveness of the hospitals. The study provides substantial theoretical and practical contributions. It expands knowledge of hospital resilience in light of recent disruptive events and promotes integration capabilities as determinants for the majority of resilience dimensions. All organisational and inter-organisational collaboration, cooperation, and coordination are deemed crucial for hospital resilience.

Exploring hospital resilience protective or risk factors: lessons for future disaster response efforts

Background

Hospital resilience is essential in responding to disasters, but current research focuses mainly on frameworks and models rather than the protection of resilience and analysis of risk factors during public health emergencies. This study aims to examine the development of resilience in Chinese frontline hospitals during the initial COVID-19 outbreak in 2020, providing insights for future disaster response efforts.

Objectives

We conducted interviews with 26 hospital staff members who were involved in the initial response to the COVID-19 outbreak in China. We used a semi-structured interview approach and employed purposive sampling and snowball sampling techniques. The interview outline was guided by the 'Action Framework' proposed by the World Health Organization (WHO) for responding to infectious disease emergencies. This framework includes dimensions such as command, surveillance, risk communication, medical response, and public health response. We analyzed the collected data using Colaizzi's seven-step data analysis method and the template analysis method.

Results

WHO's 'action framework' effectively highlights the factors that contribute to hospital resilience. While medical response, including the availability of materials and facilities, the use of information technology, and the capacity for infectious disease diagnosis and treatment, remains crucial, other important aspects include awareness and beliefs about infections, treatment experience, interdisciplinary collaboration, and more. Additionally, it is essential to establish an intelligent command system, foster trusting partnerships between teams, improve monitoring capabilities for infectious disease agents, enhance risk communication through information synchronization and transparency, strengthen infection control planning, and improve environmental disinfection capabilities for effective public health emergency response. These contradictions significantly impact the enhancement of hospital resilience in dealing with major infectious disease outbreaks.

Conclusion

In responding to sudden major infectious diseases, hospitals play a vital role within the healthcare system. Enhancing hospital resilience involves more than just improving treatment capabilities. It also requires effective command coordination at the hospital level, infection control planning, and the deployment of intelligent equipment. Additionally, planning for effective communication and coordination between hospitals, communities, and the national healthcare system can further enhance hospital resilience.

Principles and practices of designing for resilient performance: An assessment framework

Although resilient performance is intrinsic to socio-technical systems it might be supported by design, an idea known as Design for Resilient Performance (DfRP). Considering that such design is usually a re-design, learning from existing systems is crucial. This article introduces a framework for assessing the extent to which a system uses practices and principles of DfRP. The framework allows for the assessment of 24 attributes of the principles, the analysis of their relationships (a model was devised based on a survey with experts), and the investigation of practices that operationalize the principles. A scoring system sheds light on the effectiveness of using the principles. The framework application is exemplified based on the study of an emergency department in which daily huddles stood out as a practice of DfRP. This study involved interviews, observations, and documentary analysis. Based on this, a knowledge structure of DfRP is presented, comprised of concepts, principles, and practices. Six propositions to guide the framework application are set out, addressing themes such as the need for cost-effective DfRP, short control cycles, and customized designs that meet preferences of designers. The study contributes to DfRP theory and offers a new approach for resilience assessment.

How Hospitals Overcame Disruptions in the Early Stages of the COVID-19 Pandemic: A Case Study from Tokyo, Japan

The COVID-19 pandemic has caused serious disruptions to health systems across the world. While the pandemic has not ended, it is important to better understand the resilience of health systems by looking at the response to COVID-19 by hospitals and hospital staff. Part of a multi-country study, this study looks at the first and second waves of the pandemic in Japan and examines disruptions experienced by hospitals because of COVID-19 and the processes through which they overcame those disruptions. A holistic multiple case study design was employed, and two public hospitals were selected for the study. A total of 57 interviews were undertaken with purposively selected participants. A thematic approach was used in the analysis. The study found that in the early stages of the pandemic, faced with a previously unknown infectious disease, to facilitate the delivery of care to COVID-19 patients while also providing limited non-COVID-19 health care services, the case study hospitals undertook absorptive, adaptive, and transformative actions in the areas of hospital governance, human resources, nosocomial infection control, space and infrastructure management, and management of supplies. The process of overcoming the disruptions caused by the pandemic was complex, and the solution to one issue often caused other problems. To inform preparations for future health shocks and promote resilience, it is imperative to further investigate both organizational and broader health system factors that build absorptive, adaptive, and transformative capacity in hospitals.

A resilience view on health system resilience: a scoping review of empirical studies and reviews

BACKGROUND

Prompted by recent shocks and stresses to health systems globally, various studies have emerged on health system resilience. Our aim is to describe how health system resilience is operationalised within empirical studies and previous reviews. We compare these to the core conceptualisations and characteristics of resilience in a broader set of domains (specifically, engineering, socio-ecological, organisational and community resilience concepts), and trace the different schools, concepts and applications of resilience across the health literature.

METHODS

We searched the Pubmed database for concepts related to 'resilience' and 'health systems'. Two separate analyses were conducted for included studies: a total of n = 87 empirical studies on health system resilience were characterised according to part of health systems covered, type of threat, resilience phase, resilience paradigm, and approaches to building resilience; and a total of n = 30 reviews received full-text review and characterised according to type of review, resilience concepts identified in the review, and theoretical framework or underlying resilience conceptualisation.

RESULTS

The intersection of health and resilience clearly has gained importance in the academic discourse with most papers published since 2018 in a variety of journals and in response to external threats, or in reference to more frequent hospital crisis management. Most studies focus on either resilience of health systems generally (and thereby responding to an external shock or stress), or on resilience within hospitals (and thereby to regular shocks and operations). Less attention has been given to community-based and primary care, whether formal or informal. While most publications do not make the research paradigm explicit, 'resilience engineering' is the most prominent one, followed by 'community resilience' and 'organisational resilience'. The social-ecological systems roots of resilience find the least application, confirming our findings of the limited application of the concept of transformation in the health resilience literature.

CONCLUSIONS

Our review shows that the field is fragmented, especially in the use of resilience paradigms and approaches from non-health resilience domains, and the health system settings in which these are used. This fragmentation and siloed approach can be problematic given the connections within and between the complex and adaptive health systems, ranging from community actors to local, regional, or national public health organisations to secondary care. Without a comprehensive definition and framework that captures these interdependencies, operationalising, measuring and improving resilience remains challenging.

COVID-19 Pandemic Did not Influence Number of Oncologic and Emergency Surgeries: A Retrospective Cohort Study from a Tertiary Hospital in Austria

BACKGROUND

Many articles described a massive decline in surgical procedures during the COVID-19 pandemic waves. Especially the reduction in oncologic and emergency procedures led to the concern that delays and cancelling surgical activity might lead to a substantial increase in preventable deaths.

METHODS

Overall numbers and types of surgery were analysed in a tertiary hospital in Austria during the winter period (October-April) from 2015/16 to 2021/22. The half-years 2019/20, 2020/21 and 2021/22 were defined as pandemic half-years and were compared with the mean results of the previous, four, pre-pandemic half-years.

RESULTS

A reduction was found for overall numbers and elective surgeries during 2019/20 (4.62%; p < 0.0001 and 12.14; p < 0.0001 respectively) and 2021/22 (14.94%; p < 0.0001 and 34.27; p < 0.0001 respectively). Oncologic surgery increased during 2021/22 (- 12.59%; p < 0.0001) and remained unchanged during the other periods. Emergency surgeries increased during 2019/20 (- 6.97%; p < 0.0001) and during 2021/22 (- 9.44%; p < 0.0001) and remained unchanged during 2020/21.

CONCLUSIONS

The concern that the pandemic led to a decrease in oncologic and emergency surgeries cannot be supported with the data from our hospital. A flexible, day-by-day, resource allocation programme with central coordination adhering to hospital resilience recommendations may have helped to adapt to the impact of the COVID-19 pandemic during the first three pandemic half-years.

Attributes and Organizational Factors that Enabled Innovation in Health Care Service Delivery during the COVID-19 Pandemic - Case Studies from Brazil, Canada and Japan

Innovation by health service organizations can enable adaptation to and transformation of challenges caused by health shocks. Drawing on results from case studies in Brazil, Canada, and Japan, this study looked at innovations the study hospitals introduced in response to challenges caused by COVID-19 to identify: 1) attributes of the innovations that make them conducive to adoption; and 2) organizational factors that facilitate the creation and implementation of innovative health care approaches during health system shocks. Qualitative information was gathered using key informant interviews, participatory observations at the study hospitals and a review of relevant documentation. A thematic approach was used for analysis, and a cross-country comparison framework was prepared to synthesize findings from the case studies in the three countries. In response to the disruptions caused by COVID-19, the study hospitals undertook innovative changes in services, processes, organizational structures, and operational policy. The driving force behind the innovations was the need and urgency generated by the unprecedented nature of the pandemic. With COVID-19, if an innovation met the perceived needs of hospitals and provided an operational advantage, some level of complexity in the implementation appeared to be acceptable. The study findings suggest that for hospitals to create and implement innovations in response to health shocks, they need to: have adaptive and flexible organizational structures; build and maintain functioning communication systems; have committed leadership; ensure all staff share an understanding of hospital organizational and professional missions; and establish social networks that facilitate the creation and implementation of new ideas.

Sustainable Healthcare Depends on Good Governance Practices

Effective leadership and governance are at the heart of creating and maintaining resilient health systems. COVID-19 exposed a plethora of issues in its wake, most notably the need to plan for resilience. Facing threats that swirl around climate, fiscal solvency, and emerging infectious diseases, healthcare leaders are challenged to think broadly on issues that affect operational viability. The global healthcare community has offered numerous approaches, frameworks, and criteria to assist leaders in creating strategies for better health governance, security, and resilience. As the world exits the worst of the pandemic, now is the time to plan for the sustainability of those strategies. Based on guidance developed by the World Health Organization, good governance is one key to sustainability. Healthcare leaders who develop measures to assess and monitor progress toward strengthening resilience can achieve sustainable development goals.

Enabling Transformational Leadership to Foster Disaster-Resilient Hospitals

Hospitals' operational performance during disasters varies from failing, to being responsive and resilient, to dealing with disruption and surprise. Transformational leaders enable continuously learning hospitals that are resilient in the face of disasters by adapting regeneratively and evolving beyond undertaking conventional lesson-learning after each disaster. However, learning from successful transformational leaders in healthcare is still ad hoc with a lack of guidance on how to develop such leaders. Hence, this study sought to identify key competencies of transformational leaders by exploring hospital leaders' actions in dealing with disasters, considering the disaster cycle of prevention, preparedness, response, and recovery (PPRR). A qualitative case-study design was adopted comprising in-depth semi-structured interviews with twelve senior hospital staff with operational leadership experience with disasters. Three significant categories (themes) and seven key component competencies (sub-themes, in brackets) of transformational leaders were revealed through the analysis of transcripts: (1) 'Governance and leadership' ('transformative agency' and 'decisive accountability'); (2) 'Planning and risk assessment' ('risk navigation', 'disaster attunement', and 'planning agility'); and (3) 'Communication and network engagement' ('communication accelerator' and 'collaboration innovator'). The authors propose a transformational leadership model for hospital disaster resilience and an assessment checklist for leaders' self-reflection to support hospitals in their transition to resilient operations.

Role of hospitals in recovery from COVID-19: Reflections from hospital managers and frontliners in the Eastern Mediterranean Region on strengthening hospital resilience

Background

COVID-19 highlighted the critical role that hospitals play throughout the prolonged response and continuous recovery stages of the pandemic. Yet, there is limited evidence related to hospitals in the recovery stage, particularly capturing the perspectives of hospital managers and frontliners in resource-restrained and humanitarian settings.

Objective

This paper aims to capture the perspectives of hospital managers and frontliners across the Eastern Mediterranean Region on (1) the role of hospitals in recovering from COVID-19, (2) Hospitals' expectations from public health institutions to enable recovery from COVID-19, (3) the Evaluation of hospital resilience before and through COVID-19, and (4) lessons to strengthen hospital resilience throughout the COVID-19 recovery.

Methods

A multi-methods approach, triangulating a scoping review with qualitative findings from 64 semi-structured key-informant interviews and survey responses (n = 252), was used to gain a deeper context-specific understanding. Purposeful sampling with maximum diversity supported by snowballing was used and continued until reaching data saturation. Thematic analysis was conducted using MAXQDA and simple descriptive analysis using Microsoft Excel.

Findings

In recovering from COVID-19, hospital managers noted hospitals' role in health education, risk reduction, and services continuity and expected human resource management, financial and material resource mobilization, better leadership and coordination, and technical support through the provision of updated clinical evidence-based information from their public health institutions. Qualitative findings also indicated that hospital managers attributed considerable changes in hospitals' resilience capacities to the pandemic and suggested that strengthening hospitals' resilience required resilient staff, sustainable finance, and adaptive leadership and management.

Conclusion

Hospitals are the backbone of health systems and a main point of contact for communities during emergencies; strengthening their resilience throughout the various stages of recovery is critical. Hospitals cannot be resilient in silos but rather require an integrated-whole-of-society-approach, inclusive of communities and other health systems actors.