Major incidents are defined as the result of a vast ecological breakdown in the relationship between humanity and environment for which extraordinary measures, often necessitating outside or international help, are required to cope with them.Reference Ryan, Mahoney, Greaves and Bowyer1 Preparedness involves arrangements to ensure that all resources and services that may be needed to cope with the effects of major incident can be rapidly mobilized and deployed.Reference Bulut, Fedakar, Akkose, Akgoz, Ozguc and Tokyay2, Reference Seyedin, Aflatoonian and Ryan3 It builds better coordination and cooperation between agencies within the community and improves response to the effects of a major incident by organizing the delivery of timely and effective rescue, relief, and assistance.Reference Seyedin and Jamali4, Reference Seyedin and Ryan5
Organizations that are prepared for major incidents have the ability to recover approximately two to three times faster, and with significantly less financial and human cost, than organizations that are unprepared.Reference Seyedin, Ryan and Keshtgar6, Reference El Subbaugh7 However, organizations tend to be more reactive rather than proactive in their approach and are concerned more with relief efforts than with mitigation and preparedness.Reference Flynn8, Reference Seyedin9 The reasons for this lack of foresight may be lack of executive power, lack of awareness, or lack of political will to implement mitigation and preparedness programs.10, Reference Mitroff11
The city of Bam, which is located in southeastern Iran in Kerman province, belongs to the catchment area of Kerman University of Medical Sciences. On December 26, 2003, at 5:26 AM, the city lay in ruins, shattered by an earthquake that lasted just 10 seconds and measured 6.5 on the Richter scale. It devastated more than 90% of the city center, surrounding villages, and historic buildings, and killed more than 30 000 people.Reference Emami, Tavakoli and Alemzadeh12, Reference Mohebbifar, Tabibi and Asefzadeh13 Health organizations in Kerman province and across the country were mobilized to respond to the earthquake.
Previous research has shown that previous experience with major incidents increase a manager's awareness and political will to employ major incident management programs.Reference El Subbaugh7, Reference Seyedin9, Reference Mitroff11 We investigated the emergency preparedness of experienced and nonexperienced health organizations, mainly in response to the Bam earthquake, to understand the extent to which preparedness and response requirements were employed. The aim of the study was to analyze the findings and propose recommendations for improvements that can be useful in developing countries.
Methods
To collect the data in Iran, a qualitative method that used a purposive, stratified, and nonrandom sampling method and a semistructured interview technique was chosen. This methodology was preferred because it allows an in-depth exploration of managers’ views and belief about major incident management.Reference Punch14-Reference Bryman16 A total of 65 health managers such as hospital, health network, and health center managers at the local level; health deputy, treatment deputy, and head of major incident taskforce at the provincial level; and health ministry together with health managers in Bam and Kerman University of Medical Sciences were interviewed by one of us (H.S.). A protocol was used for the interviews, which included asking the participants about their background; the nature of their activities; mitigation and preparedness; their previous experience of major incidents; any involvement in major incident response; and effects of major incident on current major incident activities within their organizations (Appendix). Before starting the interviews, the interviewer explained details of the research project and the definition of a major incident, as given here. Interviews were performed from July 2009 to December 2009 in the managers’ office and lasted between 20 and 78 minutes, averaging approximately 46 minutes. Before tape recording the interviews, the interviewees’ consent was obtained and confidentiality assured. The majority of the interviewees agreed to the interviews being recorded. Thereafter, the interviews were transcribed.
To analyze the data, a framework analysis developed by Ritchie was used.Reference Tashakkori and Teddlie15 To enhance the analysis of data, a software package designed to facilitate the analysis of qualitative data (At-las.ti 5.5) was used. Initial thematic framework and codes were developed using the interviews, prior thoughts, literature, and research questions. The authors coded all segments of the text and compiled themes by the codes. In the process of data analysis, the thoughts of separate interviewees were reconstructed into a meaningful category by the processes of data reduction, combining the same or similar codes, induction, and identifying new meaningful ideas emerging from the gathered data. To increase the credibility of the analysis, a triangulation technique was applied.Reference Bryman16-Reference Lewis and Ritchie18 This technique entailed discussing the results of the analysis with some of the interviewees and major incident management experts to incorporate their comments and suggestions in the final analysis.
Results
A broad range of views was expected, given the diversity of major incident activities and requirements. However, the responses relating to the themes that emerged from the interview were remarkably consistent among interviewees. These responses were incorporated into the following main themes.
Major Incident Experience and Preparedness
The interviewees explained how previous major incidents positively affected their preparedness and response. Some talked about cholera and how cholera outbreaks increased their preparedness.
“As it has happened before, everybody knows what to do during the outbreak. AH personnel are educated and appropriate actions are taken each year during summer season.” (Manager [M]2)
The interviewees indicated that although organizations were not properly prepared during the Bam earthquake, at present, organizations are more interested in preparedness activities.
“… we have learned from the earthquake many things. We were not prepared at the time of the [previous] earthquake while now the story is different. Currently there are more major incident preparedness activities, education and communication in our system.” (M24)
Some managers reported the current value of experiences and lessons learned by staff during the Bam earthquake and other major incidents.
“We sent our teams to Bam. They were there for six months. They experienced and learned many things and now their knowledge is a great value for us and really useful.” (M11)
War between Iran and Iraq was another example in which participants stated that it had a large effect on the personnel's major incident management knowledge.
“Our preparedness goes back to the war with Iraq. I mean those who were in the war, experienced many things, for example, many casualties were coming to the health system at one time, so they tri-aged them; discharged those with fewer wounds; and added some beds even in the corridors, etc.” (M38)
In addition, some discussions were about how positively the Bam experience affected the response of health organizations in the Zarand earthquake, which occurred 14 months later in the same geographical area. All of the interviewees who were involved in the earthquake in Bam acknowledged that their response to the Zarand earthquake was much improved.
“The Bam earthquake caused some changes in the major incident structure and encouraged the health system to run many workshops. Therefore, there were changes both in knowledge and operations. Our first major earthquake after the Bam earthquake was in Zarand in 2005: 600 people died and 40 villages were ruined. We did not ask anybody outside our university for help. All organizations knew what to do and jobs were performed in a very experienced manner. The Bam experience helped us hugely to perform as well as we did.” (M56)
A senior manager in Bam claimed that theirs was the first team with full equipment, despite their far distance, to arrive at Zarand. Another senior manager in Neishabour (where a train explosion in 2004 killed nearly 300 people) made the same statement concerning the arrival of their team to the Ghaen earthquake in 2005.
All of the interviewees fully supported the statement that there is a positive relation between prior major incident experience and raising the level of preparedness. However, most of the participants felt that these benefits were individually dependent and short term.
“Major incident management activities are for short term and individually based. If a person who has been involved in a previous major incident and has a lot of experience leaves the organization we will need to start from zero as he takes out all experiences with himself. Such experiences need to be recorded for future use by others.” (M30)
Policy, Rules, and Standards
Most of the managers believed that among the main problems in the major incident system, the one that is most obvious concerns the lack of major incident policy and rules in the health system at different organizational levels. Also, the policies and regulations were not made into rules or backed up systematically.
“Two years ago when the earthquake struck Bam, our centre like other organizations started to do something. Some committees were formed; equipment prepared … but because there was no documented policy and structure behind it, after some time everything was forgotten. So we think if we want to do the right job, we must construct the substructures, prepare strategic plans and execute them.” (M5).
Interviewees believed that major incidents had some positive effects on policy making and setting rules. For example, M1 stated that the Arqe Mosque fire in Tehran (2006) forced senior managers to think about their bed distribution policy and encouraged them to take action and create more burn treatment capacity.
Incident Command System and Emergency Operation Center
Principals concerning an incident command system (ICS) and emergency operation center (EOC) must be properly considered and practiced. Participants believed that their system needed major revision, and they debated over ICS principals in the event of major incidents.
“The main problem in Bam was the diversity of decision-making centers and lack of a unique command system. This caused inappropriate resource distribution, parallel services delivery, etc.” (M14)
Furthermore, the majority of interviewees mentioned that they do not have such a facility in their organization, in spite of the fact that they had found it to be necessary.
Evaluation and Assessment
Little discussion focused on damage and major incident assessment teams in the event of major incidents. A damage assessment team was dispatched to the Zarand earthquake to evaluate the situation. Two participants from Kerman University mentioned that they were in the process of preparing and educating these teams after the Bam earthquake (M33, M23).
“Two surgeons went to the scene in Zarand and did the damage and needs assessments.” (M26).
Professional Education
It was observed that some universities (although only a few) were trying to enhance major incident knowledge of managers and personnel. One of the universities, Kerman University, has been leading the way in this area. This university has run some workshops and short-term courses after the Bam earthquake.
“We have invited some experts to come and educate our staff and create some frameworks of major incident in their mind.” (M16)
Contingency Planning
Some major incident events are frequent or recurring. The participants understood the actions and requirements for dealing with some of these frequent events such as the fires that occur during the ancient Iranian festival of Chaharshanbeh-Souri (dating from at least 1700 BC, this festival of fire is a prelude to the ancient Nowruz festival, which marks the arrival of spring, revival of nature, and New Year in the Persian calendar), cholera epidemics, outbreaks of leishmaniasis, and others. However, for some rare major incidents such as earthquakes, fires, and explosions the majority of the participants cited that they do not have a prepared plan.
“Some incidents such as fire or power loss have happened in our hospital. We must have a contingency plan for each ofthese, but we don't have any yet.” (M19)
Drill
At the local level, some rehearsals and exercises in hospitals and public health departments were noted. Some others were planning to have such rehearsals; however, this did not apply to all organizations.
“We sometimes run drills in our hospital. The last one was some weeks ago.” (M57)
At the regional level, some internal drills were conducted by health organizations such as health departments in some universities. Except for Kerman University, where all of the internal and external organizations were involved, no information indicated a multi-organization drill among all organizations within or outside the university.
Coordination and Cooperation
Coordination was one of the main concerns among the interviewees. Inappropriate coordination originated from parallel services delivery of organizations such as social security, armies, banks, and Red Crescent organizations, which deliver health services and have their own hospitals and health facilities (M18, M20, M26). Coordination was also one of the most important lessons of the Bam earthquake (M40).
“One of our main problems is lack of coordination. We saw this problem in Bam. Everybody wants to help, so he does whatever he can; as a result jobs are mixed with no clear responsibility and too many interruptions.” (M50)
Lessons Learned and Institutional Memory
A variety of ways is available to transfer lessons learned about major incidents to other organizations and the next generation: debriefing; recording and documenting all processes; reporting to senior managers; publishing the experience; and conducting workshops and seminars. Although some workshops and seminars have occurred after some major incidents (M22, M29), none of the participants explained the ways in which lessons could be learned.
Media Engagement
Appropriate timing in informing the media was a lesson learned from the Bam earthquake. Insufficient knowledge about how to deal with the media, content, and time of announcements caused many difficulties, confusion, and disruptions.
“Local TV and other media in Kerman province constantly were asking everybody for help. We saw thousands of people from different cities, especially those who had relatives in Bam, come to Bam. We realized that Bam is no longer under control as thousands of people had come for help.” (M49)
This lesson helped managers assign and educate one person to deal with the media during future disasters.
“In the Mashhad aircraft crash in 2006 I did not do an interview with anybody. We were responsible just for rescue efforts. When the media correspondents came to me for the interview I just told them I will not do any interview I am not responsible for. My duty is just to rescue people.” (M62)
Discussion
Many authors have suggested that organizations that have experienced major incidents in the past should exhibit a greater preparedness for future major incidents. These organizations should have gained knowledge about how to respond to future major incidents.Reference Seyedin and Jamali4 An organization that has had previous experience in major incidents has been associated with more preparedness activities, as compared to an organization which has not experienced such events.Reference El Subbaugh7, Reference Zaboli, Tovfigh and Seyedin19, Reference MacFarlane, Joffe and Naidoo20
The most effective factor that leads managers to begin a program of major incident management is direct, personal experience of a single or repeated series of major incidents.Reference Pauchant and Mitroff21 In a survey of 30 or so organizations, executives were asked to indicate the effectiveness of various strategies for convincing top management to adopt a program in major incident management. Direct personal experience of a major incident was opted for as the best strategy among 12 others.Reference Seyedin9 Administrators, chiefs of staff, emergency center physicians, and experienced head nurses appear to have imprinted their experiences in their personal memories and have adapted these experiences to the next catastrophe. This adaptability is undoubtedly as valuable, if not more so, than the written major incident plan or mandated drills.Reference Mattox22, Reference McCormick and Wardrope23
In the current study, it was found that previous major incidents positively affect response, preparedness, policy making, and resource management. The Bam earthquake encouraged organizations to invest more in preparedness activities. The experience gained as a result of the major incident at Bam provided Iranian health officials with a valuable learning opportunity and identified areas in which improvements can be made to respond to such a disaster quickly and efficiently so that loss of life in the immediate aftermath of an earthquake is reduced to a minimum.Reference Akbari, Farshad and Asadi-Lari24 The Bam experience positively affected the response of health organizations in the Zarand earthquake. The organizations believed that, although the scale of Zarand earthquake was smaller, the response was more coordinated; fewer problems were revealed; enough depots for drugs and equipment were available; and the dispatch of casualties was very quick.
Considering the findings, we believe that a positive relation exists between major incident experience and improved preparedness. This means that lessons learned from previous major incidents were used to produce more effective activities. However, our findings showed that these preparedness activities were individual dependent and possibly only effective in the short term. For instance, for one or two years after a major incident, the system will attempt to focus on preparedness activities, but as the effects of the incident fades, activities also will be reduced. A new, redesigned system is needed to analyze the lessons and document, discuss, and report to the primary organizations or incorporate the lessons into the legal system by creating evidence-based policies, regulations, and changes in the existing structure and system across the country.
Results of a survey of local small businesses in Grand Forks, North Dakota, after the flood of 1997 showed that business owners who experienced the flood did not significantly increase their level of major incident planning compared to levels immediately before the flood. Also, it was found that businesses started after the flood had significantly higher levels of major incident planning than those that were trading before the flood.Reference Flynn8 These findings, which are supported by our research, indicated that it should not be assumed that organizations systematically increase their levels of major incident planning after experience of a major incident.
Limitations
Our study has some limitations. We defined some inclusion criteria, then selected 65 managers and interviewed those who were in a position of senior management with at least six months of working experience. This selection process precluded including the views of lower-level front-line responders. In five cases, the managers had been recently appointed, so we located and interviewed the former managers. Also, some information in the organizations was considered confidential. In some cases, this restriction prohibited managers from discussing issues of the major incident freely. Moreover, perceived preparedness of respondents might not have equated with actual preparedness and quality of response.
Conclusions
To our knowledge, this study is the first of its kind to have been conducted in Iran. Our findings have shown some effects of experience in major incidents on major incident preparedness activities and some malfunctions of the system. To improve the existing situation, we recommend the following:
• an appropriate major incident system should be designed at local, regional, and national levels to bring the lessons learned from previous major incidents into major incident planning and preparedness;
• staff should be trained on major incident issues and how to communicate with media;
• major incident policies, protocols, and standards need to be properly considered;
• organizations should consider implementing an incident command system (ICS) as a commanding tool for responding to major incidents;
• a system should be developed for future audits of the health organization's performance after a disaster or drill; and
• a national networking database for disaster-related information should be created.
Although this study concerned activities in Iran, lessons for health organizations can be applied in other developing and developed countries, especially in the Middle East, where the same system of disaster management exists. We believe that the implementation of these recommendations would produce an improved disaster management system in most countries.
Published online: July 31, 2012. doi:10.1001/dmp.2012.34
Appendix: The Interview Protocol
Would you please introduce yourself?
• What is the structure of major incident management at your organization?
• Would you please explain about your policies and plans for a major incident?
• Do you have any protocol and guidelines regarding a major incident?
• If you have experienced any major incident recently, please explain how your organization handled it and did it have any effect on the preparedness of your organization?
• Please imagine a hypothetical major incident happens to your organization. Would you please try to predict how your organization would handle such a major incident, who informs you, and what are your first activities?
• If the major incident was about the Bam earthquake, an aircraft crash, an ark mosque fire, and/or the Neishabour explosion, please explain about the process you did and your experiences?
• Do you have a control room?
• Would you please explain about the teams, their educations, and maneuvers? What about education, do you have any major incident education for newcomers and personnel?
• If there is anything of relevance to add to this interview, and I have not asked about it, I would appreciate it if you would comment on it.
