Pan American Health Organization · 1st edition, 2024 · 132 pages
Operational framework for hospital managers and emergency planners to strengthen facility resilience across prevention, preparedness, response, and recovery phases.
- Issuer
- Pan American Health Organization
- Edition
- 1st edition, 2024
- Audience
- Hospital managers, department heads, hospital emergency management committees, health authorities responsible for disaster risk management in health facilities
- Evidence
- Expert consultation with multidisciplinary global professionals and synthesis of WHO/PAHO emergency management frameworks including SMART Hospitals Initiative
- Reviewed
- 16 Oct 2026 · GMJ
What this guideline says
GMJ summary
This inter-regional PAHO/WHO guidance establishes a comprehensive operational framework for building hospital resilience to health emergencies and disasters. The framework is built around five components (space, staff, stuff, systems, strategies) and four core attributes (safe and sustainable, inclusive and equitable, agile and adaptable, continuously learning). Resilient hospitals maintain critical functions and provide high-quality, continuous care amid crises while leaving no one behind.
The guidance is structured around three phases: BEFORE (routine operations, risk assessment, risk reduction, and preparedness), DURING (emergency response and compensatory risk management), and AFTER (recovery, reconstruction, and lessons learned). It emphasizes mainstreaming health emergency and disaster risk management (HEDRM) into routine hospital operations rather than treating it as an add-on activity. The approach integrates structural safety (hard resilience) with operational capacity (soft resilience).
Key interventions span strategic risk assessment using the STAR-H toolkit, structural and nonstructural mitigation, establishment of hospital incident management teams (HIMT) and emergency operations centers (H-EOC), mass casualty and fatality management, communicable disease outbreak preparedness, supply chain resilience, staff capacity development, and after-action review processes. The framework links hospital resilience to broader goals of universal health coverage, global health security, disaster risk reduction, and climate adaptation.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Conduct regular multi-hazard risk assessments using the STAR-H (Strategic Toolkit for Assessing Risks in Health Facilities) five-step approach to identify hazards, vulnerabilities, and capacities
- Establish a multidisciplinary hospital incident management team (HIMT) with clearly defined roles including incident commander, operations, planning, logistics, and finance/administration sections
- Designate and equip a hospital emergency operations center (H-EOC) as the central coordination hub with communication tools, information systems, and resource management capabilities
- Develop tiered activation levels for emergency response with defined triggers (e.g., Level 2: 10 actual patients or 3 major trauma patients; Level 3: 20 patients or 5 major trauma; Level 4: 50+ patients)
- Implement cohort grouping during infectious disease outbreaks with separate wards for infected patients, including appropriate areas for family members and visitors
- Pre-identify hospital spaces for mass casualty response including patient reception/triage, treatment areas by priority, decontamination areas, evacuation zones, and alternative care sites
- Maintain emergency supply stockpiles with minimum 48-hour supply of critical items for minor incidents, 24-hour for moderate incidents, and establish fast-track emergency procurement procedures
- Conduct mandatory after-action reviews (AAR) following every incident using standardized trigger questions to identify strengths, challenges, and develop corrective action plans within defined operational periods
Hospital Response Activation Matrix
Table extracted from the guideline
| Activation level | Definition/parameters | Authority to activate | Notification |
|---|---|---|---|
| 1 Alert/notification | Information indicating potential unusual impact on hospital operations | Administrator on duty (business hours) or nursing supervisor (other times) | Administrator on call, EU charge nurse, incident commander, environmental/engineering supervisor, health systems EOC, safety/security officer, telecommunications, local government |
| 2 Minor Impact | EU: 10 actual patients or 3 major trauma; >4 hours wait; >50% above normal census; 1-10 patients above licensed bed count. Logistics: 15% staff unavailable; 48-hour supply critical items remaining | Incident commander | Same as Level 1 plus other department managers as warranted |
| 3 Moderate Impact | EU: 20 actual patients or 5 major trauma; >8 hours wait; >100% above normal census over 8 hours; 11-30 patients above licensed bed count. Logistics: 25% staff unavailable; 24-hour supply; vertical evacuation needed; >8 hours duration | Incident commander | Administrator, EU charge nurse, emergency management coordinator, environmental/engineering supervisors, health system EOC, nursing office, safety/security, telecommunications, department managers, local government/public health EOC |
| 4 Major Impact | EU: 50 actual patients; >12 hours wait; >200% above normal census; 31-50 patients above licensed bed count. Logistics: 40% staff unavailable; critical shortage; complete building evacuation; >24 hours duration | Incident commander in consultation with hospital CEO | All Level 3 contacts plus hospital CEO |
Source: Pan American Health Organization, Resilient Hospitals: An inter-regional guidance on strengthening resilience to health emergencies and disasters in health facilities. Reproduced in summary form.
From the guideline
Verbatim
“Resilient hospitals must remain functioning, as they provide high-quality and continuous critical, life-saving, and essential services, amid crises, while leaving no one behind.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of the Public Health Institute of Georgia and having consulted on health systems strengthening across the region, I find this framework directly applicable to our context where seismic risk intersects with emerging infectious disease threats and climate-related hazards. The most critical recommendation for Georgian hospitals is establishing functional Hospital Incident Management Teams with clearly defined activation triggers and job action sheets—during COVID-19 we saw that hospitals with pre-existing coordination structures adapted far more effectively than those improvising. The STAR-H risk assessment methodology should be integrated into Georgia's hospital licensure requirements alongside existing quality standards. The realistic implementation challenge is financial: while the framework rightly emphasizes that resilience investments protect the 70% of health budgets typically allocated to hospitals, Georgian facilities will need technical assistance to mainstream these competencies into routine operations rather than treating emergency preparedness as an unfunded mandate competing with clinical priorities.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 16 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia and the South Caucasus face multiple hazards including seismic risk, seasonal flooding, landslides in mountainous regions, and cross-border health security threats. Since establishing its universal health coverage programme in 2013, Georgia has expanded hospital capacity but emergency preparedness infrastructure remains variable across facilities. The framework’s emphasis on mainstreaming HEDRM into routine hospital operations aligns with ongoing reforms in hospital accreditation and quality standards. Georgian hospitals would benefit particularly from the STAR-H risk assessment methodology, given the region’s seismic vulnerability, and from strengthening hospital incident management systems to interface with the national Emergency Management Service. The guidance’s integration of infection prevention and control with disaster preparedness is directly applicable to Georgia’s experience managing COVID-19 and preparing for potential cross-border outbreaks. Implementation would require coordination between the Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs, the Emergency Management Service, and hospital licensure authorities to incorporate resilience standards into accreditation criteria.
Questions this guideline answers
Quick answers
What are the four core capacities of a resilient hospital?
The four capacities are: (1) Absorptive – resist or withstand the shock of a health emergency without loss of function; (2) Adaptive – respond with alternate resources to maintain essential functions and meet immediate community needs; (3) Transformative – recover rapidly at sensible cost, reduce vulnerability, and improve readiness for future emergencies; (4) Learning – review and reflect on past actions to inform future responses, question assumptions, and change learning structures. These capacities are applied throughout the prevention, preparedness, response, and recovery (PPRR) cycle.
How should hospitals organize their incident management structure during an emergency?
Hospitals should establish a Hospital Incident Management Team (HIMT) led by an incident commander with four main sections: Operations (manages tactical objectives and response activities), Planning (collects/analyzes information, maintains resource status, develops incident action plans), Logistics (provides resources and services to support the response), and Finance/Administration (monitors costs, financial matters, and reimbursement). The team operates from a designated Hospital Emergency Operations Center (H-EOC) with communication systems, information displays, and resource tracking tools. Clear job action sheets define immediate (0-2 hours), intermediate (2-12 hours), and extended (>12 hours) tasks for each position.
What is the STAR-H toolkit and how is it used?
STAR-H (Strategic Toolkit for Assessing Risks in Health Facilities) is a five-step hospital risk assessment approach: (1) Establish a multidisciplinary committee responsible for risk assessment; (2) Record previous events from internal and external hazards; (3) Develop a schedule to review documentation and analyze each hazard; (4) Document the process to systematize subsequent reviews; (5) Incorporate results into the emergency and disaster response plan to develop/revise specific response protocols. The tool assesses four dimensions: likelihood of hazard occurrence, severity of impact on occupants and operations, vulnerability, and coping capacity. It generates hazard-specific risk scores with recommendations.
How can hospitals prepare for mass casualty incidents when resources are limited?
Hospitals should develop a mass casualty management plan that includes: (1) Pre-identified spaces for patient reception, mass casualty triage, emergency care, and alternative care sites (corridors, lobbies, auditoriums); (2) Coordination mechanisms with local authorities and other hospitals to distribute patients and avoid overwhelming single facilities; (3) Tiered activation levels with specific triggers (e.g., 10 patients = minor, 20 = moderate, 50+ = major response); (4) Support from non-medical services (engineering for lifelines, administration for emergency procurement, security for access control, nutrition for extended operations); (5) Emergency supply stockpiles with minimum 24-48 hour reserves of critical items; (6) Partnerships with vendors through pre-established mutual aid agreements for rapid resupply. Planning should include both first responder coordination for controlled patient transport and internal hospital service coordination.
Related on GMJ
Interconnected resources
Dictionary of Public Health
GMJ News coverage
Quality & accreditation
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- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 1st edition, 2024
- Status
- Current
- Published
- 2024-08-29
- Languages
- English (original), Spanish version available
- Scope
- All-hazards hospital resilience framework applicable to facilities of all complexity levels in all settings
- Audience
- Hospital managers, department heads, hospital emergency management committees, health authorities responsible for disaster risk management in health facilities
- Pages
- 132
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-75-12906-7 (PDF)
- Evidence
- Expert consultation with multidisciplinary global professionals and synthesis of WHO/PAHO emergency management frameworks including SMART Hospitals Initiative
- Record history
- Created 16 Oct 2026 · updated 16 Oct 2026 · next check Apr 2027
Pan American Health Organization. Resilient Hospitals: An inter-regional guidance on strengthening resilience to health emergencies and disasters in health facilities. Washington, D.C.: PAHO; 2024. Available from: https://doi.org/10.37774/9789275129067GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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