Document Type: Review Article

Authors

1 Department of Health in Emergencies and Disasters, School of Public Health, Tehran University of Medical Sciences, Tehran,I.R.IRAN.

2 Pre-Hospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran

3 1- Department of Emergency Medicine, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran 2- Pre-Hospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran

4 Department of Health in Emergencies and Disasters, School of Public Health, Tehran University of Medical Sciences, Tehran,I.R.IRAN

5 Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran

Abstract

Objective: To examine all aspects affecting the functioning of the system and the most important factors in its assessment through a systematic review during 1990 to 2017.
Methods: This systematic review of the current literature study was conducted during July 2017, and all articles, books, guidelines, manuals and dissertations pertaining to the Incident Command System were analyzed. A total of articles and relevant documents were identified and finally these articles, which we found, were analyzed based on the specified indicators.
Results: In this research 992 articles and relevant documents were identified and eventually, 48 articles were included and analyzed. The results were categorized into 6 main groups including 65 subgroups and 221 variables: features  of hospital incident command system (14 subgroups and 53 variables), strengths of the system (15 subgroups and 70 variables), weaknesses of the system (10 subgroups and 15 variables), factors influencing the system's performance improvement (12 subgroups and 42 variables), factors that reduce the  effectiveness of system  include 11 subgroups (10 internal factors and 1 external factor) and 22 variables and important factors in assessing system performance (2 sub-groups and 19 variables).
Conclusion: According to the results, Evaluating the effectiveness of a hospital accident command system (HICS) in a valid method can improve the efficiency of this system. In this appraisal, hospital managers and health decision-makers should consider principles, characteristics, strengths and weakness of it.

Keywords

Introduction

 

Today, the occurrence of unexpected incidents around the globe affects governments and nations causing a great number of fatalities and significant economic losses.  Despite many recent advances, incidents and disasters remain one of the most important concerns of a man's life [1]. Therefore, it is important to pay more attention to the development of plans, principles on natural disaster reduction and their effects, as well as the proper management of disaster risk reduction [2]. Among the many components involved in crisis management, relief and rescue in emergencies, healthcare centers, especially hospitals, play a major role [3]. Due to the lack of predetermined structures for proper management and focus on activities and training programs, these healthcare centers may expose to multiple risks and performance dysfunction [4]. Therefore, hospital preparedness is the main element of disaster management programs, which should be based on a standard protocol [5].  One of the invaluable management instruments which has an effective role in empowering services of health‑care centers according to global experiences is the Hospital Incident Command system (HICS) [6]. Hospital Incident Command system is a management system used to help manage incidents in unexpected situations and makes an attempt to build a coordination between hospitals and other institutions involved through using a rational and integrated management structure, responsibilities and duty description, creation of transparent reporting channels, and building a simplified and commonplace terminology system [4,7]. Regardless of their size or ability to provide care for the patient, health centers, especially hospitals, can use the system for planning and responding at all-hazard emergency situations [8]. According to the reports published by the organizations in the United States, the system has been able to improve the quality of delivered hospital services in crisis situations very effectively and offered many effective crisis management plan and strategies for the hospital [4]. HICS was designed in 1991 as one of the strategies of hospitals for contrast with disasters with the mission of prevention, mitigation, response, and recovery in hazards [6]. The Hospital Incident Command System (HICS) is widely used by hospitals, yet there is a paucity of research and a lack of developed models to examine HICS implementation [6 ,9]. In addition, our review shows that there has been no comprehensive study analyzing the positive or negative aspects of the system [9]. Perhaps the importance to develop HICS for emergencies has led scholars to ignore its qualitative aspects [6]. Therefore, in order to improve the effectiveness of Hospital Incident Command System, the current study aimed to assess the effectiveness of system with a focus on its features, strengths, weaknesses, factors contributing to the increasing and decreasing of system effectiveness, as well as important factors involved in system assessment. The aim of the current study was investigating and categorize factors affecting HICS effectiveness with a focus on its features, strengths, weaknesses, factors contributing to the increasing and decreasing of system effectiveness, as well as important factors involved in system assessment to improve the effectiveness of HICS. Therefore, the findings of this study can increase the knowledge of decision makers about the HICS in order to improve hospital readiness and respond appropriately during accidents and disasters.

 

Materials and Methods

 

Data source

A systematic review was conducted to investigate published studies and documents relating to the factors affecting the performance of Incident Command System.

This research was conducted during July 2017.All articles, books, guidelines, manuals and related dissertations were extracted from January 1, 1990 to July 15, 2017.   We searched databases including PubMed, Ovid, Springer, Scopus, science of the Web and Google Scholar, Medline for foreign articles, and Iran's Medicine and SID for Persian articles. In addition, we searched ProQuest databases for relevant dissertations. Relevant articles were identified by searching citations and using the snowball mechanism.

 

Search Strategy

Other than the articles searched using the snowball method, the rest of the articles included in the study was searched using Medical Subject Headings (MeSH) resource: ICS OR "Incident Command Systems" OR "hospital incident command system" OR "hospital emergency incident command system "OR" Incident Command Structure "OR" Incident management framework "AND utilization OR evaluation OR effectiveness OR" Measures of effectiveness "OR performance OR implementation OR assessment OR application OR ORGANIZATION or strengths OR weak points AND" Emergency Operation Center "OR out -of hospital "OR" EOC "OR" Pre hospital "" hospital "OR" Emergency medical system ".

 

Inclusion criteria

The inclusion criteria were: articles published in the scientific journals and were relevant to research questions, published in English language and only allocated to Hospital Incident Command System in hospital and pre-hospital settings, Hospital Emergency Operation Center (HEOC) and health centers.

 

Exclusion criteria

The exclusion criteria were as follows: published papers before 1990, published in non-academic journals, not relevant to research questions, not in English and duplicate publications. Further, articles and texts were analyzed using descriptive and thematic approaches. Quality assessment of included studies was done via PRISMA checklist. Figure 1 presents a flow diagram of data collection and its analysis. The included studies in the current systematic review are summarized in Table 1 and the categorization of the included articles based on their strengths and subjects is demonstrated in Table 2.

 

Fig. 1. Flow diagram of the search and selection of papers

 

Table1. Papers analyzed for the systematic review of literature.

 

Author

Country

Year

Category

Methodology

Objective

Location of system use

Data source

Howard Backer

USA

2014

Guidebook

reviewing  qualitative  studies

Updating  the Incident Command System Guide

hospitals -health CentersEmergency departments in the

hospitals  at National and local levels

 

Louis N. Molino,
Sr

Canada

2006

Book

reviewing  qualitative  studies

This book points to the applicability of this system for the management of hospitals  at  the incident scene , and even to the use of it  for incidents involving a large number of patients with trauma -induced stress.

hospitals

 

P. A. O’ Neill

USA

2005

Original article

reviewing  of qualitative texts, results of hospital teachings

Familiarizing surgeons with some principles of responding to incidents or high casualties, including the structure and principles of Hospital Incident Command System

health care facilities

hospitals

teachings

Jamal Akhavan Moghaddam

Iran

2006

Original article

reviewing  of qualitative texts

Familiarity with Hospital Accident Command System and its  implementation

hospitals

 

hospitals experiences

Lida Shams

Iran

2011

Original article

reviewing  of qualitative texts

Identification of Isfahan University of Medical Sciences Hospitals Preparedness for Establishing a Hospital Incident Command System

hospital

 

Semi-structured interview

ItaloSubbarao

USA

2011

Letter to editor

reviewing  of qualitative texts

Appropriate  Patient Triage Using Emergency Command System and Deploying Operations  center in health emergency situations

Health Emergency
Operations Center

-

Takashi Ukai, 

Japan

2005

Letter to editor

reviewing  of qualitative texts

Evaluation of the effectiveness of Hospital Accident Command System

hospital

 

-

Min Xu

China

2015

original research

literature review

Performance Evaluation of the Public Health Emergency Operations Center

health emergency
operations center

Texts

Lisa Schoenthal

USA

2015

thesis

case study

Identification of Factors Affecting the Success of the Hospital Incident Command System (HICS)

hospital 

modeling

Eleanor H. Adams,

USA

2010

Original Article

case study

Investigating the use of Incident Command System for public health threats

health care system

teachings materials

Peter Aitken

Australia

2012

original research

National survey

Application of the incident command system in DTM teams

DMAT(disaster medical assistance teams)

Mail survey

Ali S. Al-Shareef

Saudi Arabia

2017

original research

Cross sectional

Assessing hospital preparedness against disasters

Hospital 

collected data

Jeffrey L. Arnold

USA

2005

 

theoretical discussion

Literature review

Implementation of corrective actions plan of hospital emergency command system in order to adapt hospital emergency management to needs

Hospital 

interview

Simon A. Andrew

USA

2012

Original Article

review

Assessment of the problems in providing mental health services in disaster, especially the incident command system

Behavioral  and Psychological Services

texts

Karyn Jester Ayers

USA

2013

thesis

qualitative

phenomenological

Assessing the roles and capabilities of hospitals during a catastrophic response (disaster)

Hospital 

interview

Pamela Autrey

USA

2006

Original Article

qualitative

 

Investigating the Effect of Knowledge of Highly Valid Location and Teams on Implementing the Incident Command System

Hospital 

exercise and interview

Susan Miller Briggs

USA

2009

review article

Literature review

Exploring the principles of the incident command system

Firefighting centers - police and hospitals

-

Frederick M. Burkle Jr

USA

2007

Original Article

peer-reviewed literature

Investigating  the structure and functions of the incident command system needed for decision making in biological events

HEOC

-

Robert K. Kanter

USA

2011

Book (chapter 18)

-

Principles used for responding to public health threats by pediatricians

Hospitals - ICU

-

Christopher T. Born

USA

2007

Original Article

-

Better response to disasters and high-casualties incidents with an emphasis on hospital management system.

Hospitals

-

Stephen S. Morse

USA

2006

BOOK(chapter 13)

-

Disaster preparedness at health centers and emergency rooms and hospitals

Health Centers - Emergency departments - Hospital

-

AhmadrezaDjalali

Iran

2016

Original Article

Qualitative

Personnel competencies required to respond to CBRN incidents and their training needs

Hospital

Delphi

Mohammad Hossein Yarmohammadian

Iran

2011

Educational Research Article

Qualitative

Examining the Challenges, Opportunities and Strategies of the Emergency Hospital Command  System (HEICS) for hospital readiness

Hospital

semi-structured

interview

Christopher T. Born

USA

2011

Instructional Course Lectures

-

Assessing the importance of the existence of an incident command system in orthopedic surgeons in order to manage disasters in response to disasters

Hospital (surgeons)

-

Saleh Fares

Dubai

2014

Original Article

Review study- instrumentation

Analyzing Hospital Preparedness Levels against  Disasters Using HVA Tool

Hospital

Texts - Examining Hospital Experience

Nidaa A. Bajow

Saudi Arabia

2014

Original Article

Cross sectional

Assessing hospital preparedness against disasters

Hospital

Questionnaires collected from hospitals

Pam Hoffner

USA

2009

Original Article

Cross sectional

Application of hospital accident command system in physicians  with different specializations

Hospital

modeling

Ahmadreza Jalali

Iran

2012

Original Article

observational study

Measuring  the decision-making function using the task descriptions of hospital accident command system

Hospital

Orbital Maneuvering

Dick A. Buck

USA

2006

Original Article

literature review

Conclusion on the use of Hospital Accident command System as an Organizational Management Tool at Disaster Time

Labor Organizations - Public Health - Fire Department - Law Enforcement Agency

Several sources of information related to the nine different incidents

Rouhollah Zaboli

Iran

2014

Original Article

mixed qualitative and quantitative approach

Assessing hospital preparedness

Hospital

Collected questionnaires from hospitals and group discussions

David A. Bradt

Australia

2003

Original Article

Case study

Settlement management and health issues in the recovery and disaster incident rescue phase

health care centers

-

Amy H. Kaji

USA

2006

Original Article

descriptive, cross-sectional survey

Assessing hospital preparedness

Hospital

Questionnaires collected from hospitals

Jessica Jensen

USA

2016

literature review

literature review

knowledge system and the direction of future research

Hospital - fire department and others

literature review

Donald Londorf

USA

1995

special report

 

Application of Hospital Accident command System

Hospital

-

Hesam Seyedin

Iran

2013

original research

qualitative study

Assessing  of the effects of major accidents on the preparedness of health organizations in future disasters

Health organizations

semi structured interview

Wendin M Gulbransen

USA

1997

thesis

Cross sectional literature review

Mobile application in  the Hospital Accident command System of  various disaster phases

Health systems

Texts - teamwork assessment

George U. Njoku

USA

2015

thesis

quantitative design and used survey approach

Studying  the compliance of hospitals with the implementation of the components of the National Accident Command System (Incident Command System)Hospital (as one of the ways to estimate hospital preparedness

Hospitals and health systems

Collecting online information from hospitals

Allison T. Chamberlain

USA

2012

Original Article

qualitative study

Reviewing  the experiences of H1N1 flu immunization program managers in the United States

Immunization plan

electronic survey

Robert Powers

USA

2007

Feature Article

case study

Description of the successful integration of the principles of incident command in the multi-hospital disinfection program

Multi-hospital disinfection plan

Teamwork and practice

Robert W. Rendin

USA

2005

Original Article

case study

Reviewing the implementation of comprehensive tuberculosis screening programs in health care units based on the principles of the system Incident Command

Health care units

Data on the implementation of the screening plan

Rune Rimstad

Norway

2015

comprehensive review

systematic literature review

Focusing  on the commanders at  the scene in emergency pre-hospital services with High casualties

Pre-hospital emergency department

Pretext

Marsha Fishbane

USA

2012

supplement article

case study

Use of the Incident Command System in Influenza Vaccination Clinics in Populated classes

Vaccination clinic

teachings

Carl H. Schultz

USA

1996

review articles

literature review

Medical response to sudden deaths after an earthquake

Health care Centers

texts

Tamara L. Thomas

USA

2004

original research

survey

Assessment of hospital training  based on the incident command system

hospital

Information obtained from the questionnaire after the exercise

Ernest Sternberg

USA

2004

special report

 

A Searching for methods and planning terminologies  in hospital incidents to promote resilience

hospital

texts

Ahmadreza Jalali

Iran

2015

Research Article

Qualitative

Changes to improve the performance of the incident command system in 2006 version

hospital

Delphi method

Nathan L. Timm

USA

2011

original article

Cross sectional

Describing  lessons learned from the 5 years of using the Hospital Command System at the Children's Hospital

hospital

Teachings

Ming-Che Tsai

USA

2004

original article

Quantitative-survey

Assessing the efficiency of the Hospital Accident Command System during an outbreak of Severe acute respiratory syndrome (SARS)  disease in Taiwan in early 2003

hospital

Information obtained from the questionnaire by interview

Chau H. Vu

Taiwan

2012

Clinical Review

case study

This article provides basic information on the general structure of hospital emergency preparedness and specific aspects

hospital emergency department

Teachings

Xin Yantao

China

2010

original research

observational, cross-sectional survey

Hospital Emergency Command Assessment

hospital

self-administered questionnaire

Shahin Shooshtari

Iran

2017

Review Article

review study

Examining the Benefits, Obstacles and Constraints of Using HICS in the Hospital

hospital

texts

Mohammad Hossein Yarmohammadian

Iran

2013

Letter

-

Establishment of Hospital Incident Command System as one of the requirements for better response to incident

hospital

-

 

 

Table 2. Categorization of final articles based on features, strengths, weaknesses, enhancing performance factors, decreasing performance factors, and important factors in assessing the Hospital Accident Command System.

Domain

Sub category

Variable

 

 

System features that help to succeed

 

 

 

 

Structure

 

Command- Inter-organizational command- Bureaucratic- Based on military principles- Hierarchical- Rational framework- A distinct chain of Organized command

 

Language

 

Common lexical and linguistic structure- simple- common- common language

Flexibility and compatibility

 

Modular design- flexible- Compatible- comparable- Adapted to a variety of events-

Adaptation to program events- Scheduled and not-Adhere to the management structure in Changing environments

Approach

 

All hazards from top to bottom- Predetermined  calling  mechanism- Multiple protocols for response

Application at various levels

Global and international- local- National- daily activities

Having a command area and control

 

Specific command area- Appropriate Size Control- Specific monitoring area-

Predictable Chain Leadership- Clarity in monitoring

Providing an  appropriate  response

Fitted  the size of the hospital- Proportional to the extent of the incident- Assigning  individuals based on the extent and magnitude of the incident- Activating  the sections according to the type and size of the incident

Management style

Based on precise and extensive goals- Centralized- Defining  interactive management components and disaster management structure- Standard System Management Tool- Predictable Management Chain

Transparency and appropriateness of duties and responsibilities

 

Posts- responsibilities- Duties

Roles- Managerial tasks- Job Descriptions _ Individual- Description of the tasks of external  organizations- Task description sheets

Performance style

The Emergency Response technique at disaster time is not based on a real  scenario

Simplicity

Be simple

Counting feature

Positions

Team performance

Dependency

Components of response

Coloration

Specific coloration

Strengths of system use

Improved coordination

Operational-Organizational- Inter-organizational- Independent groups- Response actions- Teamwork

Improved response

Standard response- Facilitating the response- Structured and organized response- Effective- Fast- successful- Effective and efficient- Increased effectiveness- Empowerment- A powerful framework for responding- Proper operation- Resilience promotion

Resources and facilities

Provision of facilities- Providing enough medical personnel- Effective use of resource-

Employing regular human resources- Sharing  resources

improved management

Valid management protocol- Enhancing managerial empowerment - Comprehensive crisis management strategy

Preparedness status

Preparedness items- Increased hospital readiness- Increased human resource preparedness

Assessment

Quantitative and targeted structural Assessment of disaster relief- Assessment tool- Assessment system

Discipline

Reduced  chaos caused by disaster- Reduced  disruption of decision making

Planning

Improved planning

Costs and resources

Reduced costs- Cost Stability- Documentation of costs and resources- Reduced financial losses and injuries

-Effective use of resources

Communications

Providing communication system- Quick communication- Easy connection- Promotion of administrative communications- Preventing  unnecessary communications for communication- Effective communication plan

Organizational capability

In achieving  multiple goals

Reporting and Information

Facilitating information gathering- Facilitating reporting- Information acquisition- Information dissemination- Shared information

Service delivery

Saving time- Improving the quality of services- Continuity of service- Provide expansion of services

Patients

Improve the care- Treatment- Triage- Maintaining security

Personnel

Security- Increased efficiency- increasing the self confidence- team encouragement

Weakness

lack of efficiency

in big-complex incidents

Structure

Unknown military structure

lack of duplicate and reassure

Executive- Educational- Coordination

Working  with system

complicated  health systems

Inefficient response and confusion

Job description- Ownership responsibilities

inefficient  sharing

between partner organizations

failure

in health organizations

System Language

Lack of familiarity with personnel

Inactivation of system

by the leader despite training

scope of job descriptions

Wideness

Factors affecting in increasing efficiency

Understanding the system

Promoting understanding- Understanding and conceptualization- Knowledge

Improving the advanced skills of the system- Promoting an acquaintance culture

Training and retraining

Staff- Managers-Development of educational materials

practice

Planning to practice- implementation

Commitment to implement the system

Organizational Commitment Leadership and Leadership Commitment- Staff Commitment

coordination

regional

Financing

Removing Financial Barriers- Allocating funds- Providing Purchase opportunities

Updating and improved compliance

Plans-Policies- Practices-educational packages- Structures-activities- Processes-Executive Boundaries

Compliance with New Threats - New Technologies -Adaptation of the planning stage with the response

Assessing  the Challenges

Disaster program before response

Facilitating  procedures

Removing complex administrative procedures

Advanced Communications

Use of state of art  technologies

Improved  Command Structure and Managers

Appointment of competent managers- Leadership eligibility- Compilation of Command Description-Holding the Committee of Directors-Remove Daily Anxieties

Compilation and adherence to the rules

Design instructions-Follow the rules-Compliance with the principles of the system

Points to be considered in the organization's assessment

Measurement of system functions

Coordination functions-Command-Control-Decision making-System performance-Quantitative analysis

Assessing  the administrative departments of the system

Administrative-executive- Communication-Planning- Adaptation-coordination- Levels of command and personnel -Activating trainings-Comparative time intervals in triage-treatment - transportation - holding meetings, debriefing

Factors decreasing  system efficiency

internal barriers

Cultural

Lack of cultural management-Organizational Culture

Lack of assessment method

lack of a general method for assessing HICS - lack of a methodology for assessing health-based trainings

Problems related to managers

Lack of need - support - commitment and belief in the system-Not eligible-Lack of shared management language

Legal barriers

Lack of legal requirements-Change in the rules and the lack of unity in the command

Decision making

large number of decision makers

Financial barriers

High  expenditure 

System incompatibility

Incompatibility with existing structures in the hospital

Lack of a comprehensive plan 

Response to hospital disasters and hospital headquarters

poor communication and  coordination

External and internal team communication and coordination

Lack of competitive space

Development- Planning

External barrier

Parallel work of accountable organizations

Internal- External

 

Quality assessment

A 7-question checklist was produced to assess the quality of the retrieved publications by authors (Table 3). The Quality-related questions investigated the following components:1- Number of subgroups mentioned in the main group of hospital incident command system features 2- Number of subgroups mentioned in the main group of strengths of the system, 3- Number of subgroups mentioned in the main group of weaknesses of the system, 4- Number of subgroups mentioned in the main group of factors influencing the system's performance improvement, 5- Number of subgroups mentioned in the main group of factors that reduce the  effectiveness of system  6- Number of subgroups mentioned in the main group of variables and important factors in assessing system performance 7- The number of main groups referenced.

 

 

Table 3. Quality assessment based on the number of subgroups and main groups cited by the authors of the article

 

Total

The number of main groups referenced

Number of subgroups mentioned in the main group of variables and important factors in assessing system performance

Number of subgroups mentioned in the main group of factors that reduce the effectiveness of system

Number of subgroups mentioned in the main group of factors influencing the system's performance improvement

Number of subgroups mentioned in the main group of weaknesses of the system

Number of subgroups mentioned in the main group of strengths of the system

Number of subgroups mentioned in the main group of hospital incident command system features

First Author

15

2

0

0

0

0

6

7

Backer H

13

2

0

0

0

0

6

5

Molino Sr LN

14

2

0

0

0

0

5

7

O'Neill PA

18

3

0

0

2

0

6

7

Akhavan Moghaddam J

15

3

0

0

2

0

4

6

Shams l

2

1

0

0

0

0

1

0

Subbarao I

8

3

0

2

0

0

2

1

TakashiUkai M

6

2

0

0

0

0

1

3

Xu M

19

5

2

1

4

0

1

6

Schoenthal L

7

2

0

0

0

0

4

1

Adams EH

7

2

0

0

0

0

4

1

Aitken P

4

2

0

0

0

0

1

1

Al-Shareef AS

3

1

0

0

2

0

0

0

Arnold JL

7

3

0

0

2

1

1

0

Andrew SA

4

2

0

0

0

0

1

1

Ayers KJ

7

2

0

0

3

0

2

0

Autrey P

8

3

0

0

2

0

1

2

Briggs SM

4

2

0

0

1

1

0

0

Burkle FM

7

2

0

0

0

0

4

1

Kanter RK

10

3

0

0

1

0

2

4

Born CT

10

3

0

0

0

2

1

4

Morse S

5

2

0

0

0

0

2

1

Djalali A (2016)

24

4

7

0

4

0

4

5

Yarmohammadian MH (2011)

7

2

0

0

0

0

2

3

Born CT

8

2

0

0

0

0

1

5

Fares S

5

2

0

0

0

0

1

2

Bajow NA

4

1

0

0

0

0

3

0

Hoffner P

7

3

2

1

1

0

0

0

Djalali A (2012)

5

2

0

0

0

1

3

0

Buck DA

3

1

0

0

0

0

0

2

Zaboli R

3

1

0

0

0

0

2

0

Bradt DA

3

1

2

0

0

0

0

0

Kaji AH

6

2

0

0

2

0

-

2

Jensen J

9

3

1

0

0

0

2

3

Londorf D

3

1

0

0

2

0

0

0

Seyedin H

4

1

0

0

0

0

0

3

Gulbransen WM

4

2

0

0

0

0

1

1

Njoku GU

4

1

0

0

0

0

3

0

Chamberlain AT

5

2

0

0

0

0

2

1

Powers R

8

2

0

0

0

0

3

3

Rendin RW

6

3

0

0

1

1

0

1

Rimstad R

8

2

0

0

0

0

1

5

Fishbane M

5

2

0

0

2

0

0

1

Schultz CH

6

2

0

2

0

0

2

0

Thomas TL

7

2

0

0

0

0

4

1

Sternberg E

6

2

1

0

3

0

0

0

Djalali A (2015)

8

2

0

0

1

5

0

0

Timm NL

5

2

0

0

1

0

0

2

Tsai M-C

7

3

0

0

1

0

1

2

Vu CH

3

1

0

0

0

0

2

0

Yantao X

13

2

0

0

0

0

6

5

Shooshtari S

14

3

0

0

7

0

3

1

Yarmohammadian MH (2013)

Thematic analysis

In the first step, one researcher analyzed the extracted data of each publication by thematic method (PB), In the second phase, the draft analysis was reviewed by the second researcher (AY), this appraisal continued until two researchers had agreed on themes and sub-themes was attained. Any disagreement or mismatch was resolved through discussion and involvement a third researcher (AOT).

 

Results

 

A total of 992 articles and documents were searched and finally 52 articles were analyzed based on the specified indicators. The data were analyzed descriptively. Most of the reported citations were related to the United States (59.6), Iran (19.2), China (3.8), Saudi Arabia (3.8) and Australia (3.8). About 92.26% of the articles included in the study published from 2014 to 2017 and 9.51% from 2006 until the end of 2013, concurrent to the fifth and fourth editions, respectively, by the Hospital Incident Command System. An approximately 23% of the articles used either absolute or qualitative approaches and 5.11% were case studies. In addition, the focus of the selected articles ranged from the application of the system in the hospital or pre-hospital system (4.63%), health centers (3.17%), both hospital and health centers (6.7%) and Hospital Emergency Operation Center (HEOC) (7. 5%).Therefore, according to the results, the hospital and pre-hospital settings had the highest rate of system referrals. The abstracts of the relevant articles and documents are shown in Table 1.

 

Thematic analysis

The results were categorized into 6 main groups, 65 subgroups and 221 variables as follows: features  of hospital incident command system (14 subgroups and 53 variables), strengths of the system (15 subgroups and 70 variables), weaknesses of the system ( 10 subgroups and 15 variables), factors influencing the system's performance improvement (12 subgroups and 42 variables), factors that reduce the  effectiveness of system  include 11 subgroups (10 internal factors and 1 external factor) and 22 variables and important factors in assessing system performance (2 sub-groups and 19 variables).

 

Principles and features effective in the success of the hospital emergency hospital system:

The hospital incident command system is a management system for controlling, commanding and coordinating the activities of independent groups. This system is designed to achieve the common goal of incident prevention, reduction of mortality, financial losses and severe damage. The system has several features that contribute to achieving these goals and affect its success. The present study indicated that there are several significant features affecting the effectiveness of hospital incident command system including the organized command structure [10] based on the same principles and compliance with the key structure of the incident command [9,11,12] use of a bureaucratic framework based on military principles [13]. This system is characterized by an organizational form of the structure [6], hierarchical structure [13-15], and a specific command chain [16]. In addition, this system provides an appropriate and reliable structure for leadership regardless of the incident type [17]. A clear spoken language —based on the common [4,6,9-12, 16, 18], simple and commonplace [4,18] terminology is another feature of the system.the  hospital incident command system can define specific  organizational functions and roles through job descriptions [11, 19,20], rational tenets for the allocation and organization of occupational activities [14] clarify the precise managerial tasks and responsibilities [21], access to a list of personal job descriptions [22], positions [4, 18],  responsibilities [4, 18, 20, 23, 24],  individuals duties [4, 7, 16, 18, 23, 25- 28], external  organizations [28], responsibilities of hospital incident command system team [29],Specifying specific roles in an organizational table [22,23], and consequently  prioritize  tasks based on the job description worksheets [6] and recruit  the personnel when it becomes necessary[30]. Additionally, numerous studies have focused on other structural features of Hospital Incident Command System including modularity  [12], flexibility [13-16, 19, 23,31],  both  flexibility  and modularity  [4, 6-8, 11, 14, 18, 32], analogy  and comparison [9], compatibility [17], adaptability in crisis situations  at a variety of scales [17,18, 23], and category  [26,31] and concordance  with planned and unplanned events [33] and effective for management in potentially changing environments [10].  The hospital incident command system is based on the principles and characteristics mentioned. Applying these principles and features will ensure the utilization of resources and reduce policy discrepancies and the operations of accountable organizations.

 

Strengths of system use

Setting up a precise, efficient and cost-effective managment system is one of the main pillars of disaster management programs in hospitals. The hospital incidnet command system brings significant benefits to hospitals and plays an important role in improving the quality and delivery of services during emergencies and disasters in hospitals. Hospital incident command system provides a powerful framework [10] standard template [8], structured and organized incident response [16] and facilitates emergency incident response [19]. various advantages for hospital incident command system including provision of the most reliable management protocols [18], and comprehensive crisis management strategy [8] can apply to improve the management capabilities of the emergency [31]. HICS develops strategies for effective and efficient dealing with crisis situations [4], accelerates effective and quick response [8,11], increases effectiveness [18, 23], enhances efficiency and effectiveness of the response plan [31, 34], facilitates communication between different units of the system in emergency incidents [35], fosters problem solving process among the organizations involved [22,25] and ultimately, reduces the chance of errors and parallel work [25].

Hospital incident command system provides a response planning [36] this system can offer hospital of all sizes with  an opportunity  to plan, prepare  and respond  to  both emergency and non-emergency situations,  make  other relevant  units  and organizations take part in the emergency response depending upon the size and type of incident  [4, 18], extend or limit the size, scope, and complexity of an incident, assign particular tasks or position based on the magnitude of the incident [8] accelerates effective and quick response [8,11] and consequently guarantees the successful implementation of the plan [37]. Furthermore, numerous studies have mentioned another strength of the system including: detection of system capabilities by other organizations [8], providing a system for coordination [12] coordination between hospitals [4, 23, 38] and accountable organizations [4,6-8, 23], coordinating activities among independent groups and coordinated response actions [6] coordinated response to emergencies situations [8, 11, 35, 39], coordinated multi-disciplinary response to public health threats [28], mutual efforts [40], decentralization in decision-making [10] and building unity in dealing with complex and extreme crises, making   incident command system known to the public [7].

Additionally another advantages for  hospital incident command system including improvement of administrative communications [8, 9], developing   a system [12] and communication plan [6], quick and easy communication with other crisis management systems in various rescue and relief departments [4], and facilitated communications [16, 24] between hospitals , Medical emergencies and other responsible organizations [12] and foreign organizations [10], clear inter-organizational communication [39], inter-team environmental awareness [41],  avoidance of unnecessary communications [26], improved communication [42, 43], and existence of effective communication plans [6]. Hospital incident command system with some its features can lead to the  cost minimization [4, 18, 22, 23]: provision of  accurate and timely documentation on spending and resource utilization, [11] reduced  financial losses and severe injuries, [6] effective use of resources, [22] provision of  adequate and efficient medical facilities and personnel [39], effective use of all resources for problem solving [17], provision of resources and equipment [30,44], provision of health care  facilities for emergency management [33], use of manpower on a regular basis [45], providing health facilities needed for emergency management [33], regular staffing [45] and sharing resources in organizations and health care centers [6, 11]. So considering the strengths of this system, HICS has been identified as one of the factors necessary to boost resilience [42], hospital empowerment [6], incident management and reduced fatalities [6], response to daily operations and emergency and non-emergency situations [22].

 

Weakness of system use

according to reports, since the system was initially developed for use in a military and hierarchical structure, it makes hard for the providers of public health system to use the system because of cultural differences [19]. Buck DA and colleagues also stated in their study that although the system was successful in firefighting organizations, it has not been successful in some organizations, such as public health [45]. Similarly, SA Andrew et al. questioned the usefulness capabilities of system in reducing organizational disputes, especially at large-scale incidents and events [46] and FM Burkle et al. found that the system is unable to manage the complexities of a large-scale health-related disasterespecially epidemic situations [47].  the main disadvantage is that the structure cannot be changed or be reliable in terms of training, coordination and administrative capability [48].Furthermore, Timm NL et al. reported that hospital staff were completely unfamiliar with the language system and were unable to use terms such as logistics, operations, financial to explain leadership roles [48].The vastness of the range of job descriptions in the system is another weakness of the system [48] Likewise, NL Timm et al. noted the inefficiency of the system in real time response and exposure to stress [48]. Some studies have also referred to high cost as one of the other problems in the system [23]. R Rimstad’s findings suggesting that system sharing between partner organizations is a major problem [13]. 

 

Factors affecting in increasing efficiency

Considering the importance of the incident command system in managing and responding effectively to emergencies and disasters, and given the widespread use of this system in hospitals in the world, it is essential to pay attention to factors that increase its efficiency. Therefore, it is important to pay special attention to several factors for increasing the effectiveness of the system within the hospitals, including familiarity with the organizational structure of the system [18], creation of cluster structures for the system at the planning stage depending on the response phase [47] determining the organizational hierarchy of the structure based on the requirements rather than the titles [17] development of units, positions, description of new duties in accordance with hospital requirements [14] definition of job description and supervision of managers [22] and providing training and information to managers at all levels for creation of a common language and building culture [23].

The application of advanced communication technology to coordinate and provide critical information between incident command teams [41] has been one of the most important elements in improving system performance, furthermore It is necessary to pay special attention to regional coordination plays a significant role in the promotion of system efficiency [49]. Also the existence of transparent reporting channels [7, 20, 23-25] and transmission of information to high-level authorities [10] are the two main aspects of the incident command system, which can facilitate the information collection, reporting [28], sharing information [31], information acquisition and information dissemination [50]. In order to improve the effectiveness of the system, some additional measures need to be taken: removing financial barriers to implement the system, [23] financing the hospital to establish the system, [23] providing procurement opportunities for staff and offices to strengthen the crisis management culture [15], supporting the Ministry of Health and taking into account additional funding for promotion of system [22].compliance with the rules and regulations [23], compliance with instructions and guidelines among the personnel and medical staff [37], enhancing compliance with the system principles [35] developing   guidelines and regulations for hospitals and legal requirements [22].

Taken together, improving the effectiveness of the Hospital Incident Command  System depends on understanding and recognizing the features and principles of the system [12, 18, 23, 37],  training employees in order to understand the system [9, 23,50],   holding continues specialized training courses [9],  implementing  exercises and procedures [10,24,41],  building  an administrative  commitment and support for managers [9], creating an interest in the personnel [22],  matching the system to the needs, updating and implementing the native version of the system [4, 49] eliminating financial barriers [22, 23] and complex and challenging administrative obstacles [22],  appointment of competent, experienced and qualified managers [13, 22] and  understanding the strengths and weaknesses of the system. 

 

Factors decreasing system efficiency

In contrast to the above finding, Timm NL et al. showed that while implementing the system, the conflicts from confused job responsibilities and roles can lead to inefficiencies in response and real implementation of the system may be failed [48] and the incompatibility of this system with the management structure of hospitals can decrease the system's effectiveness [49]. YarMohammadinia et al. found that the lack of legal requirements with continuous regulatory change, and the absence of unity of command [23], can weaken and decrease   the system's efficiency and effectiveness [23]. Furthermore, the lack of a general method for assessing HICS and hospital-based exercise programs [25], lack of cultural management for crisis command, lack of the need to create this system by managers, lack of support and commitment from authorities and managers, shortage of qualified managers at all levels, paying attention to daily activities by managers, lack of a common management language [23] and lack of senior management commitment to system implementation of the [9] can attenuate system performance.

 

Points to be considered in the organization's assessment

Assessing the hospital incident management system leads to identifying the weaknesses, strengths, decreasing factors and increasing the efficiency of the system. By identifying these factors and improving them, the efficiency of the incident command system can be improved.

The hospital incident command system has been recognized as a vital tool for meeting the compliance with accreditation requirements [8] The hospital incident command system also provides opportunities for quantitative and targeted structural assessment [51], assessment of hospital preparedness, processes, identifying, locating and recovering errors [41], exercises for preparedness against disasters [51], and finally creates an assessment system [12]. Also, in evaluating the system, all the levels and functions of the system [51], including the administrative and executive support, planning and adaptation, communication, decision-making, exercises, training and retraining [9] in a real or simulated disaster to be quantitatively and accurately analyzed [23]. Assessing the functions of the hospital incident command system is essential and useful, for example, the effectiveness of the coordination function of the system can be assessed by examining the implementation of cross-measures in accordance with the instructions of the mutual interlocutors [35] and reviewing the coordination with local and foreign authorities [9].

 

Conclusion

 

Hospital incident command system is one of the hospital's essential requirements for coping, respond and managing emergencies and disasters. The condition of applying and improving the efficiency of this system is to recognize the principles, characteristics, strengths and weakness of it by hospital staff and managers. It is also necessary to assess and evaluate the performance of the system and its functions with a scientifically valid method. Continuous assessment and recognition of the problems and strengths of the system will improve its efficiency. Therefore, hospital managers and health decision-makers need to plan and done the HICS's assessment, identify its strengths and problems, and train its principles and characteristics for hospital settings.

 

Conflict of Interest: None declared.

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