business continuity plan - wa health...effective: 6 july 2015 wachs south west busselton health...

Business Continuity Plan WACHS South West Busselton Health Campus

WA Country Health Service Working together for a healthier country WA

Effective: 6 July 2015

WACHS SOUTH WEST Busselton Health Campus

Business Continuity Plan

AUTHORISATION This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction. This plan has been formally endorsed by the following personnel (and approved by the Regional Director) as the Standard Operating Procedures to be followed in the event of such a resource failure or malfunction. The BCP should link in with existing Emergency Response Procedures Manual, and as such, should be read in conjunction with those document to make sure all staff are familiar with the procedures for both external and internal emergencies/disasters should the resource failure escalate, or be of significant magnitude as to effect the functioning of the Hospital and risk patient care. Approved

Jeremy Higgins Operations Manager - Coastal

Dated: 3 July 2015 Endorsed

Kerry Winsor, Regional Director WACHS-South West

Dated: 6 July 2015

Date of Last Review: July 2015 Page 1 of 89 Date Next Review: April 2017

Business Continuity Plan (BCP) – Busselton Health Campus

Effective: 8 October 2014

VERSION CONTROL

Amendment Entered Version

No. Page Number Date Change Description

2 1 02/10/14 Paragraph 3 entered Emergency Response Procedures Manual.

2 2 02/10/14 Version control table, merged signature and date columns, retitled column to Change Description.

2 5 02/10/14 Hospital Health Coordinator title changed to Emergency Controller/Emergency Officer.

2 9 02/10/14 Assumptions, dot point 4, deleted ‘the plans of’

2 9 02/10/14

Assumptions dot point 6, changed escalation process from site, to tier 4 Manager, to RHDC, to DPMU or SHICC.

2 9 02/10/14 Assumptions dot point 7 entered ‘from DPMU or SHICC’

2 10 02/10/14

Legislation and other standards - Deleted Standards Australia, AS/NZS HB 221-2004, Business Continuity Management

2 10 02/10/14

Deleted 5 Standards and Guidelines, Support Function Standard 2.1 & Corporate Function Standard 3.2 and entered EQuIP Guidelines Standard 15 criteria 7.

2 10 02/10/14

Governance Arrangements , deleted Hospital Emergency Coordinator and replaced with applicable Tier 4 Manager

2 10 02/10/14 Governance Arrangements paragraph 2 changed HHC to Emergency Controller.

2 11 02/10/14 Roles and responsibilities entered for RHDC, Tier 4 Manager and Emergency Controller.

2 12 02/10/14

Section 4 Debriefing - Deleted regional executive and entered ‘Emergency and Disaster Sub Committee for endorsement’.

2 14 02/10/14 Contact details, deleted Part 3.



DISTRIBUTION LIST This plan has been distributed as per the Business Continuity Plan.

Name Organisation Position/Function



GLOSSERY OF TERMS Business continuity Management Business Continuity Management (BCM) is a discipline that prepares an organisation for the unexpected. It is a management process that provides the framework for building the resilience to business and service interruption risks, responding in a timely manner to ensure continuity of critical business activities, and ensuring the long term viability of the organisation following a disruptive event. Business continuity plan A business continuity plan (BCP) is, in effect, a treatment plan for certain risks, the consequences of which could disrupt core functions. The plan outlines the actions to be taken and resources to be used before, during and after a disruptive event to ensure the timely resumption of critical business activities and long term recovery of the organisation. Critical business activity Although there are a wide range of business activities that are provided to internal and external customers, identification of critical business activities allows organisations to identify what businesses are essential. This allows prioritisation of services in the event of a service-level disruption to the organisation’s daily operations. Contingency maximum operating length time The contingency maximum operating length time determines how long the contingency or intervention can continue for. In some circumstances, the time may be finite, whereas in other circumstances, the contingency can continue indefinitely. Contingency plans For the purpose of this document, contingency plans refer to plans developed by the nominated person for each critical function areas which include actions to be taken in the event of a resource/s failure due to any cause. These plans are developed locally and are to include responses at ward level, support services and management/executive level.

Disaster An event, actual or imminent, which endangers or threatens to endanger life, property or the environment, and which is beyond the resources of a single organisation to manage or which requires the coordination of a number of significant emergency management activities. NOTE: The terms "emergency" and "disaster" are used nationally and internationally to describe events which require special arrangements to manage the situation. "Emergencies" or "disasters" are characterised by the need to deal with the hazard and its impact on the community. The term "emergency" is used on the understanding that it also includes any meaning of the word "disaster". Disaster plans For the purposes of this document, disaster plans refer to plans developed by the nominated person responsible for maintaining up to date plans, which include actions to be taken in the event of a major failure or disaster. Every hospital and health service should have such a plan.



Emergency Controller/ Emergency Officer The Emergency Controller/Emergency Officer is a person designated by the hospital executive to be the hospital coordinator for the purposes of coordinating the hospital response in an emergency. Each hospital will provide a rostered Emergency Controller who is available 24 hours per day for:

• being the contact position to receive/give the initial notification that the hospital is involved in a major incident/disaster

• commencing a notification process to alert other key hospital disaster stakeholders

• monitoring the overall hospital response to the situation • assuming overall command and control of the hospital's general resources and

management of its responses during the time the hospital disaster plan is activated, be it for an internal disaster or as a response to an external disaster.

Each hospital will have an appropriate system to enable this notification process to be conducted in a timely manner, as per Operational Directive 0302/10. Impact The impact defines what the effect will be if the critical business activity is lost or not available. In strategic terms, many impacts may be defined ambiguously, such as loss of assets or denial of access. This BCP will focus upon clinical and business related impacts. Maximum Acceptable Outage Maximum Acceptable Outage (MAO) is a measurement concept that enables stakeholders to make an informed decision on how long a particular critical business activity can be disrupted before the consequences become unacceptable. On-Call Clinical Officer The On-Call Clinical Officer (OCCO) (formerly the Hospital Emergency Operations Centre Coordinator [HEOC Coordinator]) is an officer with a clinical background who, on the authority of the State Health Coordinator (SHC), oversees the coordinated use of hospital resources in WA Health. On-Call Duty Officer The On-Call Duty Officer (OCDO) is the single point of entry into WA Health for notifications of all incidents or issues, including communicable diseases, environmental health, hospital service continuity and incident notification. Regional Health Disaster Coordinator A Regional Health Disaster Coordinator (RHDC) is a person designated by the CEO of the WA Country Health Service (WACHS), on recommendation by the Regional Director, to be the Regional Health Coordinator of a designated regional health service in accordance with WACHS Disaster Management Arrangement Policy 001, for the purposes of coordinating the regional health response in a major incident emergency. Relevant stakeholders Relevant Stakeholders are the key contacts or key stakeholders that must be considered in the event that State-level interventions and contingencies are implemented. Relevant stakeholders are critical to the success of the employed contingency.



ABBREVIATIONS BCM - Business Continuity Management BCP - Business Continuity Plan CEO - Chief Executive Officer COO - Chief Operating Officer CSSD - Central Sterile Supply Department CUA - Common Use Agreements DEMC - District Emergency Management Committee DFES - Department of Fire and Emergency Services DON - Director of Nursing DPMU - Disaster Preparedness and Management Unit DRP - Disaster Recovery Plans HCN - Health Corporate Network HIN - Health Information Network HHC - Hospital Health Coordinator HRT - Hospital Response Team ICT - Information Communication Technology LEMC - Local Emergency Management Committee LEOC – Local Emergency Operations Centre LOS - Length of Stay LTI - Lost-time Injury MAO - Maximum Acceptable Outage MCI - Mass Casualty Incident MOU - Memorandum of Understanding OCCO - On-Call Clinical Officer OCDO - On-Call Duty Officer OCMO - Office of the Chief Medical Officer OD - Operational Directive PABX - Private Automatic Branch eXchange RFDS - Royal Flying Doctor Service RHDC - Regional Health Disaster Coordinator SHBCP - State Health Business Continuity Plan SHC - State Health Coordinator SHEF - State Health Executive Forum SHICC - State Health Incident Coordination Centre SJA - St John Ambulance SLA - Service Level Agreement SOP - Standard Operating Procedure WA - Western Australia WACHS - WA Country Health Service WWC - Working With Children



PART ONE - INTRODUCTION

1. PREAMBLE The Public Sector Commissioner’s Circular 2009-19 states “all public sector bodies must practice risk management, regularly undertake a structured risk assessment process to identify the risks facing their organisations, be able to demonstrate the management of risks and where appropriate be able to have continuity plans to ensure that they can respond to and recover from any business disruption.” The Western Australian Department of Health (WA Health) requires all hospitals and support services to have in place Business Continuity Plans (BCPs) to ensure continuity of critical business functions in the event of failure or disruption.

2. AIM The aim of the BCP is to provide an organisational platform, which will maximise the efficiency and effectiveness of critical business and clinical functions in the event of localised resource failure. The intentions of the templates are to:

• provide a check list of critical business and clinical functions and critical support services

• assist in the preparation of contingency plans in cases of hospital resource failure • assist in the preparation of contingency plans in cases of health service wide

resource failure • assist with the development of a task list for the implementation phase.

3. OBJECTIVES

• Understand the environment within which the organisation operates, the existence of constraints and threats to the organisation that could result in a significant disruption (through conducting risk identification and assessment).

• Determine the parts of the business critical to its short and long term success (as part of the business impact analysis).

• Quantify the disruptive impact of these threats on critical business functions and processes, and identify the infrastructure and resources required to enable the organisation to continue to operate at a minimum acceptable level (through the business impact assessment).

• Document the key resources, infrastructure, tasks and responsibilities, required to support these critical business functions in the event of a disruption (developing the business continuity plan).

• Establish processes that ensure the information remains current and relevant to the changing risk and business environments (through maintenance protocols and the ongoing risk management process).

• Ensure that relevant employees, customers, suppliers and other stakeholders are aware of the continuity arrangements and, where appropriate, have confidence in their application (through BCM training and testing of the plans).



4. ASSUMPTIONS

The following assumptions have been made in regards to activating the BCP:

• All hospitals shall develop and document a service continuity plan. • The plan shall be tested and reviewed at the appropriate intervals • The plan shall include intended actions for all foreseeable disruptions to the

continuity of services provided by the hospital: − for which planning is possible − prioritised first by the impact of the disruption on service delivery (most

severe being the highest priority). • The plan integrates with other health service plans and with the SHBCP, the

result being a whole of health service continuity initiative. • The plan shall identify the extent of the hospital’s intended actions for each

foreseeable disruption. The extent of the hospital’s intended actions is to be determined in consultation with the Disaster Preparedness and Management Unit (DPMU) prior to finalisation of the plan.

• Where the hospital’s service continuity capabilities are insufficient to manage the disruption, the hospital shall contact the applicable Tier 4 Manager or the RHDC with a request for assistance. Where the regions capabilities are insufficient to manage the disruption, the RHDC shall contact DPMU or the SHICC with a request for assistance.

• Granting of a request for assistance from DPMU or SHICC results in the activation of the SHBCP and WESTPLAN - Health by the SHC.

• Responsibility for management of the response to the disruption at the site remains with the hospital (and health service). The role of the DPMU is to assist with the response as requested.

• A high level of resilience is expected of the hospital. • All evacuations resulting in internal transfer only shall be managed by the

hospital. All evacuations resulting in inter-hospital transfer shall be facilitated by the Tier 4 Manager.

• The OCDO shall be immediately notified of all disruptions that could foreseeably require the activation of the SHBCP.

• All health services are responsible for ensuring that their staff are familiar with these plans.

• It is acknowledged that not all problems can have contingencies or plans developed and that the management of any incident will be situation specific at the time it occurs.

• The SHICC shall coordinate application of the SHBCP across multiple hospitals as required.

• The DPMU shall develop Memorandums of Understanding (MOU) with agencies and service providers for major critical services (e.g. water and power).

• In the event of a major incident, the principles of WESTPLAN – Health will apply.



5. LEGISLATION AND OTHER STANDARDS Public sector bodies must submit details of their risk management policy assessment processes and continuity plans to Risk Cover in accordance with a schedule that will be provided by the Public Sector Commissioner’s Circular 2009-19 Risk management and Business Continuity Planning. Other standards and guidelines apply to business continuity planning, including:

• Business Continuity Management Guidelines, 2nd Edition (2009) RiskCover, Western Australian Government.

• Australian / New Zealand Business Continuity Management HB 221-2004. • International Risk Management Standard ISO 31000: 2009. • Australian Council on Health Standards EQuIPNational Guidelines Standard 15,

Criteria 7 • Standards Australia, AS/NZS HB 292-2006, A Practitioners Guide to Business

Continuity Management. • Standards Australia, AS/NZS HB 293-2006, Executive Guide to Business

Continuity Management. • Standards Australia, AS/NZS 5050: 2010, Business continuity – Managing

disruption-related risk. • Standard Australia AS/NZS 31000: 2009 Risk Management Principles and

Guidelines. • WA Health, Redundancy and Disaster Planning in Health’s Capital Works

Programs (2nd Ed) – January 2012. • Treasurer’s Instruction 825 Risk Management and Security.

6. WESTPLAN - Health In the event of a major incident, the principles of WESTPLAN - Health will apply. This is to ensure the greatest good is done for the greatest number and management of the incident is graduated from local to district to State level as required.

7. GOVERNANCE ARRANGEMENTS The activation of the BCP can only be authorised by the applicable Tier 4 Manager and/or the Regional Health Disaster Coordinator. Individual hospitals, health services are responsible for maintaining their individual disaster plans and ensuring they are congruent with the SHBCP. They are also responsible for ensuring that there is a contact person (i.e. Emergency Controller) available 24 hours per day should the RHDC or SHC require their assistance.

8. AUTHORITY AND PLANNING RESPONSIBILITY

The development, implementation and revision of the BCP is the responsibility of the Hospital Health Coordinator in consultation with Regional Emergency & Disaster Management Committee.



PART TWO – OPERATIONAL MANAGEMENT

1. ROLES, RESPONSIBILITIES AND AUTHORITIES Emergency management requires a structure to coordinate all actions needed to deal with incidents or disasters. This section outlines the roles and responsibilities of those persons implementing the BCP.

1.1 Regional Health Disaster Coordinator The RHDC has an operational role in rural/remote areas and is responsible to the SHC. The RHDC(s) responsibilities are to:

• notify the SHC, Regional Director, Chief Operating Officer (COO) and Chief Executive Officer (CEO) of the WA Country Health Service (WACHS) of emergency management and/or business continuity plan activation

• represent the health district at District Emergency Management Committees (DEMC).

1.2 Tier 4 Managers Tier 4 Managers are responsible to the RHDC. The Tier 4 Managers' responsibilities are to:

• notify the RHDC and the Regional Director of the WA Country Health Service (WACHS-SW) of emergency management and/or business continuity plan activation

• ensure the general resources required for the emergency response • determine when it is appropriate to return to normal operations within the

hospital and managing the recovery phase.

1.3 Emergency Controller/Emergency Officer Emergency Controllers/Emergency Officers are responsible to the Tier 4 Manager during an emergency response. The Emergency Controllers/Emergency Officers' responsibilities are to:

• assume overall command and control of the hospital’s emergency response. • represent the hospital at Local Emergency Management Committee (LEMC)

meetings. • maintenance of the hospital Emergency Response Procedures, including the

Business Continuity Plan • Other duties, as requested.

1.4 Department heads/business managers and other nominated staff

• Responsible for ensuring that the business continuity management process is undertaken within their departments / divisions.

1.5 All Staff (including contract and agency staff)

• Responsible for familiarising themselves with the local Business Continuity Plan for their workplace. Business Continuity Plans outline contingencies to respond to a local critical resource failure and provides initial response guidance to ensure continuing support to patient care whilst ensuring the safety of all people at a workplace.



2. STAGES OF ACTIVATION

The BCP will normally be activated in stages. In an impact event, these stages may be condensed with stages being activated concurrently. • Stage 1 – Alert - The alert stage is activated when advice of an impending

emergency or failure is received or, when following the occurrence of an event, it is unclear as to whether a Regional response is required. During this stage, the situation is monitored to determine the likelihood and nature of the health service’s response

• Stage 2 – Standby – The standby stage is activated when information received is sufficient to warrant preparatory activities in readiness for a response.

• Stage 3 – Response - The response stage is activated when a local emergency response is required and BCP procedures are enacted.

• Stage 4 – Stand Down - The stand down stage is activated when a response is no longer required. Recovery activities are undertaken.

3. DEBRIEFING

De-briefing should be conducted immediately after each enactment of the plan, be it either a real event or an exercise to identify lessons learned and ways for improving the BCP. A report outlining the outcomes of the event/exercise, lessons learned and recommendations for improvements should also be prepared and presented to Emergency and Disaster Sub Committee for endorsement.

4. TRAINING

Hospital sites are responsible for ensuring:

• training of staff on how and when the plan is the be used • exercising or rehearsing the plan to ensure that staff are indeed able to execute

the plan, and • putting in place a maintenance process to keep the plan current and relevant.

Training To ensure that BCM capability continues to reflect the nature, scale and complexity of the organisation it supports, it must be understood by all staff and stakeholders. The primary objective of training is to ensure that the importance of BCM is understood by all staff in the health service and they are aware of their roles and responsibilities during an emergency or crisis situation. General staff awareness training is to be delivered to all staff incorporated into the inductions programme. This should cover topics such as:

− an overview of what BCM − why is BCM important to the organisations − what the staff’s role is in an emergency − what the staff should do if the BCM plan is invoked − what the emergency contact numbers are.

More specialised and targeted training may be provided for Emergency Controllers and senior managers who have specific BCM responsibilities.



Exercising A business continuity plan is of little use until it can be validated that it is actually workable in the event of a business interruption. Exercising the plan helps to: • ensure the components of the plans are complete and current; • provide comprehensive practice for staff involved in recovery activities; • ensure awareness of key suppliers and partners of the Agency’s reliance on them

in the event of a plan invocation; • identify where recovery processes failed and the actions and costs required to

resolve • satisfy auditors and insurers with documented and tested plans.

Exercise Regimes:

Test Type Activities

Desktop review Normally conducted as one of the first plan ‘tests’, it involves a physical examination and review of the plan documentation. Aims to ensure that: • Plan document is complete and relevant to the expressed

business needs (operational and strategic). • The relevance and currency of the risk assessment, business

impact assessment and continuity plan are tested. • Inconsistencies in logical flow, resources allocations or conflict

between individual plans are recognised. Desktop scenario test

Involves a desktop walkthrough of the plan(s), with discussion guided by the use of one or more potential scenarios. The activities are based around a series of questions and answers relating to the deployment of the plans in response to changing issues in the scenarios.

Notification and call-out communications test

Activities are based around the verification of the accuracy, currency and utility of notification and call-out lists, call out trees (who you have to call) and deputised positions.

Live scenario tests

Can be conducted as a limited activation (narrow/specific scenario and/or targeted areas of the organisation) up to a full scale activation of al continuity arrangements for the organisation.

Business recovery tests

Involves the closing down or removal of access to infrastructure or resources and test the capability of recovery measures.

Desired Outcome Plan Activation Plans are activated according to the nature of the disruption and in an

appropriate authorised manner. Governance issues

Post activation governance requirements are identified as part of the response plan and are managed during after the response is activated and stood down.



An Exercise Plan should be prepared and approved by management prior to any major exercises. The Exercise Plan outlines the objectives and scope of the exercise, roles and responsibilities, assumptions and parameters, criteria for assessing the outcomes, and logistics aspects of the exercise, such as date, time, venue, transportation, and technical support. A training and testing worksheet is located at appendix 1. Maintenance A maintenance programme ensures that the business continuity plan remains current and relevant, ready to handle any crisis despite the constant change and dynamic environment that all organisations experience. It should be viewed as part of normal change management processes rather than be a separate structure. Maintenance will need to be undertaken: • when new processes are added or existing processes are modified or removed • when there is a major change to the Agency’s technology or location • after the Agency has performed an exercise • after an audit where gaps have been identified and recommendations for

improvements made • in accordance with the Agency’s BCM maintenance program.

Plan Component Maintenance Timeframe

BCM Policy Reviewed and updated bi-annually Business Impact Analysis Reviewed and updated once a year or when there are any

significant changes to the business Business Continuity Plan Reviewed and updated once a year or when there are any

significant changes to the business Contact Lists Updated every 12 months or as required.

5. CONTACT DETAILS

A listing of suppliers, key positions and their contact details are given in the contacts section of the BCP.



Effective: 8 October 2014

IMPACT RATING DEFINITIONS Impact ratings have been included to describe the severity of the service disruption based on both business and clinical outcomes. The identification of the disruption impact rating allows for the prioritisation of contingency to occur. Disruption Impact Table

LEVEL 1 2 3 4 5

IMPACT CATEGORIES

CODE Insignificant Minor Moderate Major Catastrophic

HEALTH IMPACT on PATIENT (s)

HP Increased level of care (minimal).

No increase in length of stay.

Not disabling.

Increased level of care (minimal).

Increased length of stay (up to 72 hours).

Recovery without complication or permanent disability.

Increased level of care (moderate).

Extended length of stay (72 hours to one week).

Recovery without significant complication or significant permanent disability.

Increased level of care (significant).

Extended length of stay (greater than one week).

Significant complication and/or significant permanent disability.

Death, permanent total disability.

ALL SENTINEL EVENTS.

HEALTH IMPACT ON STAFF OR OTHERS

HS First aid or equivalent only.

Routine medical attention required. Max 1 week’s incapacity/time lost. No disability.

Increased level of medical attention required. 1 week to 1 month incapacity/time lost. No significant permanent disability.

Severe health crisis and/or injuries, Prolonged incapacity or absence 1 month +. Significant permanent disability.

Death or permanent total disability.



CRITICAL SERVICES INTERRUPTION

CS No material disruption to dependent work.

Short-term temporary suspension of work. Backlog cleared in day. No public impact.

Medium-term temporary suspension of work. Backlog requires extended work or overtime or additional resources to clear. Manageable impact.

Prolonged suspension of work. Additional resources, budget, Management assistance required. Performance criteria compromised.

Indeterminate prolonged suspension of work. Impact not manageable. Non-performance. Other providers appointed.

PERFORMANCE TO BUDGET (Over or underspend )

PB Less than 1% temporary variance.

1% to 2% temporary variance.

More than 2% up to 5% temporary variance.

More than 5% to 10% variance NOT recoverable within the financial year.

More than 10%variance NOT recoverable within the financial year, or being unable to pay staff, creditors or finance critical services.

FINANCIAL LOSS

FL Less than $5,000. $5,000 to less than $100,000.

$100,000 to less than $3M.

$3M to less than $20M.

$20M +.

ORGANISATIONAL OBJECTIVES OR OUTCOMES

OO Little impact. Inconvenient delays.

Material delays. Marginal under achievement of target performance.

Significant delays. Performance significantly under target.

Non-achievement of objective / outcome. Total performance failure.

REPUTATION AND IMAGE DAMAGE

RI Non-headline exposure. Not at fault. Settled quickly. No impact.

Non-headline exposure. Clear fault. Settled quickly by Departmental response. Negligible impact.

Repeated non-headline exposure. Slow resolution. Ministerial enquiry / briefing. Qualified Accreditation.

Headline profile. Repeated exposure. At fault or unresolved complexities impacting public or key groups. Ministerial involvement. High priority recommendation to preserve accreditation.

Maximum multiple high-level exposure. Ministerial censure. Direct intervention. Loss of credibility and public / key stakeholder support. Accreditation withdrawn.

(This table has been adapted from Office of Safety and Quality, 2009, ‘Integrated Clinical and Corporate Risk Analysis Tables and Evaluation Criteria (2009)’, Department of Health, Government of Western Australia.)


Effective: < Insert Date >

APPENDIX 1: BUSINESS CONTINUITY PLAN – TRAINING AND TESTING PLAN

Title of Training or Test What type and method of training or testing will be used?

Hospital/Department/Unit involved in training or test

Location of Training/Test Length of Training/Test Objective(s) of Training or Test 1. 2. 3. 4. 5. Resources Yes No Critical Resources to be trained or tested People

Information Technology

Vital Documents - Hard Copy - Electronic Data

Facilities

Internal Dependencies

External Dependencies Exclusions from Training or Test (what will not be in the training or test?)

Support Requirements (what equipment, staffing, facilities, scripts will I need?)

Completed By: (Name and Position)

Approved By: (Name and Position)



BUSINESS CONTINUITY PLAN – TRAINING AND TESTING REPORT

Date/Time Record of events and actions taken By Whom? Date/Time Record of events and actions taken By Whom? TIME EXERCISE STOOD DOWN @____________HRS DEBRIEF / COMMENTS / EVALUATION: RECOMMENDATIONS:



OUTCOMES: PRINT NAME Signature of person completing report: Date: Tier 4 Review and Sign off: Date: Copy to Emergency and Disaster Management Committee



PART THREE – BUSINESS CONTINUITY PLAN

FORWARD

This Business Continuity Plan (BCP) documents the arrangements, systems and strategies for the management of business continuity at the Busselton Health Campus (BHC). Activation of this plan will occur at the local and regional level on declaration of relevant Emergency codes. This plan is informed by the Australian Standards and links with state level Disaster response plans to form part of a coordinated emergency and disaster management response. The plan highlights the responsibilities and obligations of Busselton Health Campus employees, contractors and other stakeholders in the continuity of business within their area and the wider Busselton Health Campus. It is important that all managers, staff, contractors, volunteers and other relevant stakeholders undertake mandatory and other regular training to ensure they are familiar with the plan and that the plan is regularly drilled and tested within the Busselton Health Campus.

Jeremy Higgins Operations Manager Coastal Busselton Health Campus

This document can be made available in alternative formats on request for a person with a disability

Contact: WACHS-SW Operations Manager Coastal (J.Higgins) Directorate: Operations TRIM Record # ED-CO-15-27675

Version: 1.00 Date Published: 7 July 2015



Table of Contents

FORWARD ................................................................................................................ 19 1. EMERGENCY MANAGEMENT FRAMEWORK .................................................. 23

1.1 Emergency Management Plan ..................................................................... 23 1.2 Emergency Management Manual ................................................................ 23 1.3 Emergency Response Procedures .............................................................. 23

1.3.1 Emergency Response Procedures .................................................. 24 1.3.2 Business Continuity Plan ................................................................. 24

1.4 Documentation ............................................................................................. 24 1.4.1 Action Cards .................................................................................... 24 1.4.2 BHC Code Communication Log ....................................................... 24 1.4.3 New Action Cards ............................................................................ 24

1.5 Organisational Details .................................................................................. 25 1.5.1 Description of Service ...................................................................... 25 1.5.2 Organisational Aim .......................................................................... 25

2. DOCUMENT CONTROL ...................................................................................... 26 2.1 Amendment Control ..................................................................................... 26 2.2 Review ......................................................................................................... 26 2.3 Distribution and Availability .......................................................................... 26

3. ADMINISTRATION AND GOVERNANCE .......................................................... 27 3.1 Authority to Plan ........................................................................................... 27

4. BUSINESS CONTINUITY PLAN ......................................................................... 28 4.1 Purpose ........................................................................................................ 28 4.2 Scope ........................................................................................................... 28 4.3 Objectives .................................................................................................... 28 4.4 Critical Business Functions .......................................................................... 29

4.4.1 Emergency Department ................................................................... 29 4.4.2 General Ward .................................................................................. 29 4.4.3 Maternity .......................................................................................... 30 4.4.4 Hospice ............................................................................................ 30 4.4.5 Pathology ......................................................................................... 30 4.4.6 Pharmacy ......................................................................................... 30 4.4.7 Renal ............................................................................................... 30 4.4.8 Ambulatory Care .............................................................................. 31 4.4.9 Outpatient Clinics/Services .............................................................. 31 4.4.10 Dental .............................................................................................. 31 4.4.11 Administration and Medical Records ............................................... 31 4.4.12 Hospital Management ...................................................................... 31 4.4.13 Engineering Department .................................................................. 31 4.4.14 Support Services ............................................................................. 32



4.5 Assumptions ................................................................................................ 32 4.6 Support and Contingencies .......................................................................... 33

4.6.1 Support ............................................................................................ 33 4.6.1.1 Information and Communications Technology (ICT) ........... 33

4.6.2 Mechanical ....................................................................................... 33 4.6.3 Hydraulics ........................................................................................ 34

4.6.3.1 Electrical Services ............................................................... 34 4.6.3.2 Medical Gases and Suction ................................................. 34

4.6.4 Contingencies .................................................................................. 35 4.7 Activation and Stand down .......................................................................... 36

4.7.1 Stages of Activation and Response .................................................... 36 4.7.2 Overall Activation and Stand down Process ....................................... 37

4.8. Operational Requirements ........................................................................... 38 4.8.1 Critical Success Factors .................................................................. 38

4.8.1.1 Emergency Department ....................................................... 38 4.8.1.2 Surgical Services ................................................................. 38 4.8.1.3 Ambulatory Care – Immunisation Nursing ........................... 38 4.8.1.4 Community Mental Health ................................................... 38 4.8.1.5 Dental .................................................................................. 38 4.8.1.6 Hospital Management .......................................................... 38

4.8.2 Internal Interdependencies .............................................................. 39 4.9 Overall Business Continuity Priorities .......................................................... 41 4.10 People .......................................................................................................... 47

4.10.1 Team Members ................................................................................ 47 4.10.2 Structure and Reporting Relationships ............................................ 48 4.10.3 Roles and Responsibilities ............................................................... 49

4.11 Contact Details ............................................................................................. 51 4.11.1 Supplier and Contractor Contact List ............................................... 51 4.11.2 Busselton Health Campus Disaster Phone Directory ........................ 54

4.12 Continuity Arrangements ............................................................................. 56 4.12.1 Coordination and Control Framework .............................................. 56 4.12.2 Overall Control ................................................................................. 56 4.12.3 Operations ....................................................................................... 56 4.12.4 Information Gathering and Planning ................................................ 57 4.12.5 Support Services ............................................................................. 57 4.12.6 Business Management .................................................................... 57 4.12.7 Communications .............................................................................. 57

4.13 Alternate Site/areas ..................................................................................... 57 4.14 Resource Requirements .............................................................................. 58 4.15 Workarounds and alternate solutions .......................................................... 59



4.16 Continuity Management Tasks .................................................................... 60 4.16.1 Emergency Department ................................................................... 60 4.16.2 General Wards ................................................................................. 61 4.16.3 Maternity .......................................................................................... 63 4.16.4 Hospice ............................................................................................ 64 4.16.5 Operating Theatres .......................................................................... 64 4.16.6 Central Sterilisation Services Department (CSSD) .......................... 65 4.16.7 Day Stay Unit ................................................................................... 65

4.17 Medical Imaging ........................................................................................... 66 4.17.1 Pathology ......................................................................................... 66 4.17.2 Supply .............................................................................................. 66 4.17.3 Pharmacy ......................................................................................... 67

4.18 Renal ............................................................................................................ 67 4.18.1 Ambulatory Care .............................................................................. 68 4.18.2 Outpatient Clinics ............................................................................. 71 4.18.3 Post-Acute Care Service ................................................................. 71 4.18.4 Dental .............................................................................................. 72 4.18.5 Administration and Medical Records ............................................... 72 4.18.6 Hospital Management ...................................................................... 74 4.18.7 Engineering Department .................................................................. 75 4.18.8 Hospital Management ...................................................................... 76 4.18.9 Engineering Department .................................................................. 77 4.18.10 Support Services ............................................................................. 79

4.19 Business Continuity Communications .......................................................... 81 4.19.1 Authorisations .................................................................................. 81 4.19.2 Continuity Messages ....................................................................... 81

4.19.2.1 Protocols ............................................................................ 81 4.19.3 Communication Means .................................................................... 82 4.19.4 Continuity Message Content ............................................................ 83 4.19.5 Levels of Notification ........................................................................ 84 4.19.6 Paging Message Guidelines ............................................................ 84 4.19.7 Tier 4 Manager Business Continuity Checklist ................................ 85 4.19.8 Maps and Drawings ............................................................................ 89



1. EMERGENCY MANAGEMENT FRAMEWORK

Within WA Country Health Service (WACHS) - South West (SW), Emergency management documentation outlines the regions strategies and systems for preventing, preparing for, responding to and recovering from emergencies. The Busselton Health Campus Business Continuity Plan (BHCBCP) forms a sub set of the WACHS-SW emergency management documentation and are designed to be read in conjunction with the WACHS-SW Emergency Management Plan, the WACHS-SW Emergency Management Manual and the Busselton Health Campus Emergency Response Procedures.

Emergency Management Documentation

Res

pons

eP

PR

R

Emergency Management

ManualEmergency

Management Plan

Emergency Response

Procedures

Business Continuity

Plan

1.1 Emergency Management Plan The Emergency Management Plan (EMP) outlines the high level approach taken toward emergency management by the regions Emergency and Disaster Sub Committee (EDSC). The Emergency Management Plan outlines the systems to prevent, prepare for, respond to and recover from emergency situations. 1.2 Emergency Management Manual The Emergency Management Manual forms part two of the region's Emergency Management Plan. The Emergency Management Manual provides facilities with information and instructions relevant to emergency operations which are appropriate to the size of the facility. 1.3 Emergency Response Procedures The WACHS-SW outlines it response to an incident in one of two main documents depending on the phase of the response to the incident. These are: • the emergency response phase - executed through emergency response

procedures • the business continuity phase - executed through Business Continuity Plans.

Typically, phases occur in a sequential order but significant overlap in phases often occurs.


https://healthpoint.hdwa.health.wa.gov.au/policies/_layouts/DocIdRedir.aspx?ID=TS4KSNFPVEZQ-210-5545



1.3.1 Emergency Response Procedures

The Busselton Health Campus Emergency Response Procedures are designed to be invoked immediately following an emergency at a facility to protect people and assets. Emergency Response Procedures are facility specific and cover: • immediate actions to be taken by the first responder; and • follow-on actions (Action Cards) to be taken by staff that forms the facilities

Emergency Management Team (EMT).

Note: Code Yellow Emergency Response Procedures outline the immediate actions taken in response to an internal event (i.e. essential service disruptions, infrastructure damage, hazardous chemical and natural incidents) which like all emergencies, may lead to the disruption of business activities and the activation of the Business Continuity Plan.

1.3.2 Business Continuity Plan The BHCBCP (this plan) sets out the actions to be followed should any incident cause or threaten to cause disruption to business functions of the Busselton Health Campus. The BHCBCP operationalises the response options identified in step 3 of the Business Continuity Management process for the resumption and continuity of critical business Functions within the Maximum Tolerable Period of Disruption.

1.4 Documentation

1.4.1 Action Cards

The Action Cards for each Emergency Response Team members role are to be completed by the relevant team member and are to be sent to the Emergency Controller for review and reporting to the Coastal Emergency Planning Committee.

1.4.2 BHC Code Communication Log

The Communications Officer will commence a Communications Log for business continuity actions following the activation of the BHCBCP. Where the business continuity response is stood down, the Administration Coordinator is to review the Communication Log for accuracy before sending to the Emergency Controller. Once received, the Emergency Controller is to attach the log to action card documentation for that event.

1.4.3 New Action Cards The Emergency Controller is responsible for ensuring that the completed Action Cards and forms are sent to the Business Continuity Officer for review and that new action cards are printed and replaced in the Emergency Packs and at Muster Points.



1.5 Organisational Details 1.5.1 Description of Service

The Busselton Health Campus (BHC) is a modern, purpose-built facility designed to facilitate patient centred care and which is underpinned by contemporary models of care. The BHC will efficiently and safely manage the health demand of the community projected to 2021/22, including a fluctuating number of visitors who are present at seasonally variable times. The BHC operates as an Integrated District Health Service for the South West and providing support to smaller hospitals in the region. The redevelopment has included the integration and collocation of community-based health care programs with the health campus to optimise timely access to safe and client focused care in the one location. The development of inpatient and emergency services at the BHC will result in improved support to the South West ‘Hub’ hospital in Bunbury and reduce the inappropriate patient transfers from Busselton to Bunbury and Perth metropolitan hospitals.

1.5.2 Organisational Aim The aim of the Busselton Health Campus is to support the WA Country Health Service – South West to provide quality, accessible health services to the people of the Naturalist District.



2. DOCUMENT CONTROL

2.1 Amendment Control The BHCBCP is a controlled document which is not to be altered other than those amendments endorsed by the Regional Director. This plan is intended to be a ‘live’ document and all suggested amendments or additions should be forwarded to the Coastal Operations Manager.

VERSION

NO DATE

RECEIVED DATE

AMMENDED DETAILS OF

AMMENDMENT INITIALS

1 - Jan 2015 Review and full rewrite of Facility Business Continuity Plan.

JH

Table 1: Amendment History 2.2 Review The Coastal Emergency Planning Committee shall review the effectiveness of this plan at least annually and provide advice of any amendments to the Emergency and Disaster Sub Committee. The Emergency and Disaster Sub Committee may review, or renew the plan when considered appropriate to do so. 2.3 Distribution and Availability The current editable version of this plan is held by the WACHS Policy unit. The plan is available electronically to all staff via the Department of Health (DoH) intranet facility - HealthPoint. Hard copies of the BHC BCP will be held in the following locations: • Emergency Response Centre – Executive Offices • Emergency Response Centre – Emergency Department • Hospital Coordinator Office • St John of God Dialysis Unit.

These Emergency Response Procedures have been distributed to the following:

NAME ORGANISATION POSITION

Online Access via Health Point WACHS Emergency Response Centre – Executive Offices WACHS Administrations Assistant

Emergency Response Centre – Emergency Department WACHS Clinical Nurse Manager

Hospital Coordinator Office WACHS Hospital Coordinator



3. ADMINISTRATION AND GOVERNANCE

3.1 Authority to Plan

The BHCBCP has been prepared and issued under the authority of the WACHS-SW Regional Director in accordance with applicable legal and other requirements.

This BCP has been formally recommended by the Busselton Health Campus District Manager, approved by the Coastal Operations Manager and endorsed by the WACHS-SW Regional Director as the standard operating procedures to be followed where a disruption of any type, disrupts business functions beyond tolerable periods.

Recommended Leeuwin District Manager

Approved

Jeremy Higgins Operations Manager - Coastal

Dated: 3 July 2015 Endorsed

Kerry Winsor, Regional Director WACHS-South West

Dated: 6 July 2015



4. BUSINESS CONTINUITY PLAN

4.1 Purpose

The purpose of this Business Continuity Plan is to: • reflect the context in which the Busselton Health Campus operates • provide the required capability to support the achievement of the Busselton

Health Campus critical objectives. 4.2 Scope

This Business Continuity Plan applies to all Busselton Health Campus controlled business activities (core services and support functions) that may be faced with a disruption of any cause. It does not apply to those activities controlled by: • Global Diagnostics Australia • PathWest • St John of God.

Note: These providers where engaged during the Business Continuity Management

process however engagement was limited to gathering information around business impacts and maximum tolerable periods of disruption which is assumed to be accurate. Third party health service providers are responsible for the development, implementation and testing of their own business continuity plans. Where critical business activities carried out at the Busselton Health Campus have upstream dependencies on these health service providers, a request may be made to them to review their Business Continuity Plans and for the provider to participate in response plan exercises.

4.3 Objectives The objectives of this Business Continuity Plan are to: • understand the environment within which the Busselton Health Campus

operates, the existence of constraints and threats to operations that could result in a significant disruption to critical business functions

• confirm business functions critical for success • quantify the disruptive impact of threats on critical business functions and identify

the maximum tolerable periods of disruption to critical business functions • document the resources, workarounds and responsibilities required to support

critical business functions in the event of a disruption • establish processes that ensure the information remains current and relevant to

the changing risk and business environments • ensure that relevant employees, customers, suppliers and other stakeholders are

aware of the continuity arrangements and, where appropriate, have confidence in their application.



4.4 Critical Business Functions For the purpose of this Business Continuity Plan, critical business functions have been defined as a function, that if disrupted for a period of up to but not greater than seven (7) days, will have significant (moderate or greater) impacts on critical objectives of the Busselton Health Campus. Figure 1 identifies the general areas responsible for the delivery of critical business functions at the Busselton Health Campus.

Emergency

Inpatient

Maternity Hospice

Surgical- Theatres

- Day Stay Unit- CSSD

Imaging

Ambulatory- nursing

- allied health

Renal

Pathology

Pharmacy and Supply

Engineering and Maintenance

Support- linen- food

- waste-orderly

- mortuary

Administration and Medical

Records

Hospital Management

Dental

Figure 1: General Areas Responsible for Critical Business Functions

4.4.1 Emergency Department • Resuscitation including trauma (1&2) • Triage • Registration • Acute care (3) • Fast track (4&5).

4.4.2 General Ward • Reversed barrier nursing for immune-suppressed patients • Discharge Planning • Acute medical care.



4.4.3 Maternity • Emergency Caesareans • Post natal care for mothers and newborns • Acute Antenatal care including health checks • Post natal operative procedures • Midwife review of ED presentations • Birthing • Home visiting Service

4.4.4 Hospice • Palliative care (Acute Inpatient) • Palliative care (Home visits) • Medical Imaging • On call reporting services • General reporting • Screening • Imaging Intensifier • Mobile Imaging Unit- ED Theatre • Interventional radiological procedures (various) • Orthopantomograms (OPG) • Computed Tomography (CT); • Plain films (fixed and mobile) • Ultra Sound (U/S)

Note: Medical Imaging is carried out by Global Diagnostics Australia whose

response plans are not addressed in the Busselton Health Campus Business Continuity Plan.

4.4.5 Pathology • Specimen Collection • Specimen Analysis • Provision of Point of Care (POC) testing equipment

Note: Pathology is carried out by PathWest whose response plans are not

addressed in the Busselton Health Campus Business Continuity Plan.

4.4.6 Pharmacy • Maintaining pharmacy stock • Imprest ordering • Non imprest ordering

4.4.7 Renal • Haemodialysis

Note: Haemodialysis is carried out by St John of God whose response plans are

not addressed in the Busselton Health Campus Business Continuity Plan.



4.4.8 Ambulatory Care • Acute Community Mental Health Services • In Patient Physiotherapy • In Patient Speech Pathology • Non acute community mental health care

Note: Ambulatory Care at the Busselton Health Campus (BHC) includes nursing

and allied health services.

4.4.9 Outpatient Clinics/Services • On site/area Post-Acute care • Off site/area Post-acute care • On site/area outpatient care

4.4.10 Dental • Emergency dental care.

4.4.11 Administration and Medical Records • Controlling and coordinating external emergency communications (i.e. Code

Brown) • Controlling and coordinating internal emergency communications

(i.e. activating Emergency Management Team). • Entering patient information into WEBPAS.

4.4.12 Hospital Management • Emergency Management (response function) • Iprocurement finance (approving supply orders) • Responding to Ministerial and Parliament enquiries. • Complaints management

4.4.13 Engineering Department • Responding to lift faults • Responding to essential service faults. • Responding to AC faults • Respond to ventilation supply faults (includes exhaust air) • Responding to nurse call bell system faults. • Responding to duress alarm faults. • Responding to CCTV system faults • Responding to access control faults. • Responding to external lighting faults • Maintaining access control systems.



4.4.14 Support Services • Delivering meals to patients • Collecting and transporting soiled dishes and waste • Storing food • Collecting soiled laundry • Supplying clean linen • Processing soiled linen (washing, drying and folding) • Ward cleaning • Managing clinical and general waste • Producing meals • Ordering and receiving food supplies • Transferring and handling patients • Coordinating cadaver viewings • Dispatching cadavers • Storing cadavers • Trucking freight (soiled and clean supplies, non-medical, surgical equipment

for CSSD, internal mail service) to other coastal sites/areas (pickup and delivery).

4.5 Assumptions The following assumptions have been made in regards to activating the Busselton Health Campus Business Continuity Plan: • The Business Continuity Plan has been tested and reviewed at the appropriate

intervals. • The Business Continuity Plan includes response options for disruptions to the

business functions. • Response options will be prioritised in accordance with the Maximum Tolerable

Period of Disruption. (Least times being the highest priority). • The Business Continuity Plan integrates with other hospital/health service

Business Continuity Plans and the WACHS-SW Emergency Management Plan, the result being a whole of health region continuity initiative.

• Where the Busselton Health Campus have insufficient resources to manage the disruption, the Emergency Controller will contact the Coastal Operations Manager or the Regional Health Disaster Coordinator with a request for assistance.

• Granting of a request for assistance from the Coastal Operations Manager or SHICC results in the activation of the WACHS-SW Emergency Management Plan by the Regional Health Disaster Coordinator.

• Responsibility for management of the response to the disruption at the site/area remains with the Emergency Controller. The role of the Coastal Operations Manager is to assist with the response as requested.

• There is a high level of resilience within the Busselton Health Campus.



• All relocations resulting in internal transfer only shall be managed by the hospital. All relocations resulting in inter-hospital transfer shall be facilitated by the Coastal Operations Manager.

• The Regional Director will be immediately notified of all disruptions that could foreseeably require the activation of the BHCBCP.

• Staff are aware of Emergency Management arrangements. • Not all threats have been identified and therefore response options not developed

and the management of these situations will be specific at the time it occurs. • Business continuity coordination will be carried out from a pre-determined Local

Emergency Operations Centre (LEOC). Where it is not practicable, the Regional Emergency Operations Centre will be used.

• The Emergency and Disaster Sub Committee have develop Memorandums of Understanding (MOU) with agencies and service providers for essential services (e.g. water and power).

• Service level agreements have been established to support the implementation of Business Continuity response options.

• In the event of a major incident, the principles of the WACHS-SW Emergency Management Plan apply.

4.6 Support and Contingencies

4.6.1 Support

The following engineered solutions/ services are in place at the Busselton Hospital to support the delivery of business functions.

4.6.1.1 Information and Communications Technology (ICT)

• Telecommunications - Phones (desk, door, cordless, emergency, mobile, satellite and smart phones), unified communications devices, teleconferencing, paging and PAX

• IT Equipment - Computers (clerical and clinical, medical imaging and result viewing, mobile computer on wheels, laptops, computer kiosk, tablet computers), printers (forms, labels and bar codes), scanners, Photocopiers, Office equipment

• Videoconferencing to Clinical spaces including bedrooms, Staff meeting and training rooms and desktops

• Networking and Servers - Wireless LAN, Wide area network connectivity to the WA Health Data Centres, LAN switches and devices, ICT servers.

• Master Clock System, Patient entertainment/information/education systems.

4.6.2 Mechanical • Heating, ventilation and air conditioning systems to all areas • Specialist exhausts systems to fume cupboards, dish washers, gas bottle

storage areas, mortuary, kitchen, chemical cabinets, recovery areas, dirty utility areas, workshops, plant rooms and isolation rooms

• Pneumatic tubing system



• Building Management System (BMS) providing automatic control and monitoring of the mechanical services systems and other services such as lighting, security, standby generator, uninterrupted power supply (UPS) units, lifts, hydraulic pumps, water, electrical and gas meters, medical gases.

4.6.3 Hydraulics • Chilled water generators and distributors • Hot water generators and distributors • Building Management System (BMS) providing automatic control and

monitoring of the hydraulic systems (e.g. pumps, water). 4.6.3.1 Electrical Services • Mains supply to the entire site/area by Western Power to power (not limited

to): − lighting and Lighting Control systems − emergency escape lighting and exit signs − telephone and Communications systems − smoke detection system − occupant warning and intercommunication system (OWIS) − clock system − nurse call system − public Address system − hearing augmentation Loop − building Management System − master Antenna Television System (MATV) − patient entertainment system.

• Standby power generation system to all essential systems; and • Uninterruptible power supply to all controlled systems.

4.6.3.2 Medical Gases and Suction • Medical gases to all clinical areas

− Oxygen − Medical breathing air − Nitrous Oxide − Carbon Dioxide

• Medical suction systems to all clinical areas • Tool air to specific areas (clinical and non-clinical).



4.6.4 Contingencies

DEPENDENCY CONTINGENCY ARRANGEMENTS

Information, Communications and Technology

• Uninterrupted Power Supply (UPS) to Central Computer Room (CCR) and Floor Communication Rooms (FCRs)

• Dual supervisor in core infrastructure • Redundant fibre connectivity between Floor Communication

Rooms and Central Computer Room • Backup Integrated Services Digital Network (ISDN) for voice

communication • CCR and FCRs outage: Refer to the Emergency Response

Procedures - Busselton Health Campus – section 10.5.7 for implementation of a workaround until the maximum tolerable period of disruption for the business function has been exceeded.

• Refer to WACHS-SW ICT Continuity Plan and BHC ICT Recovery Plan (currently under development).

Liquid Petroleum Gas • Incoming supply line of Natural Gas

Medical Air • Medical air compressor • Medical Gas Alarm Panels • Breakdown panel with bottle backup

Medical Carbon Di Oxide and Tool Air

• Medical Gas Alarm Panel • Breakdown panel with bottle backup

Medical Nitrous Oxide

• Medical Gas Alarm Panels • Breakdown panel with bottle backup • Portable NO2 cylinders, mixers and Entonox

Medical Oxygen

• Bulk oxygen gas storage cylinder (VIE) installation • F9 gas cylinder packs operating in standby with automatic

changeover to duty • Medical Gas Alarm Panels • Breakdown panel with bottle backup

Medical Suction • Medical Vacuum compressor • Medical Gas Alarm Panels • Venturi Twin o Vac units at point of use

Natural Gas • Bulk Liquid Petroleum Gas (LPG) cylinder installation

Power

• Two sources of incoming mains power • Un-interruptible power supply to controlled systems • 750KVa standby diesel generator • Switchboard Bus Tie arrangement • Back –up generator connections

Water • Two incoming supply lines (same provider) • 15Kl pressurised water expansion tank and automatic refill unit





4.7 Activation and Stand down

4.7.1 Stages of Activation and Response

The Busselton Health Campus Business Continuity Plan will normally be activated in stages. In an impact event, these stages may be condensed with stages being activated concurrently. Stage 1 – Alert The alert stage is activated by the Emergency Controller following the occurrence of an incident and it is unclear as to whether critical business functions have been disrupted. During this stage, the situation is monitored to determine the likelihood that the Maximum Tolerable Period of Disruption will be exceeded. Stage 2 – Standby The standby stage is activated by the Emergency Controller when information received is sufficient to warrant preparatory activities in readiness for a business continuity response. Stage 3 – Response The response stage is activated by the Emergency Controller in consultation with the Coastal Operations Manager or the Regional Health Disaster Coordinator when a health campus wide business continuity response is required. Plans are executed and resources are coordinated and deployed accordingly. Refer to the WACHS-SW Emergency Management Plan. Stage 4 – Stand Down The stand down stage is activated by the Emergency Controller in consultation with the Coastal Operations Manager or the Regional Health Disaster Coordinator when a business continuity response is no longer required. Sustainable strategies are in place and recovery activities are undertaken. Following stand down, continual improvement processes are carried out as per the WACHS-SW Emergency Management Manual.



4.7.2 Overall Activation and Stand down Process

Emergency Activation and Stand Down Overall Process

Emergency ControllerFirst Responders Business Continuity Officer Tier 4 Manager RHDC

Aler

tSt

and

byRe

spon

dSt

and

dow

n

Event identified

Emergency?

Carry out immediate actions

Execute EmergencyResponse

Maximum Tolerable Period of

Disruption exceeded?

Activate business continuity plan

Coordinate the response

Do you have the resources to deliver

critical business activities?

See assistance from Regional Health

Disaster Coordinator

Activate Emergency

Management Plan

Has the emergency abated

and critical business activities been

recovered?

Stand down the response

Resolve locally

Continual imrpovement

Continual imrpovement

End End

YES

YES

YES

NO YES

NO

NO

Figure 2: Overall activation and Stand Down process



4.8. Operational Requirements This section outlines the level of capability critical business functions must achieve, key internal interdependencies and identifies the maximum tolerable periods of disruption per critical business functions.

4.8.1 Critical Success Factors

Listed below are outputs which demonstrates that an appropriate level of service is being met.

4.8.1.1 Emergency Department • 100% of Category 1 emergency patients are seen within 2 minutes of triage • 80% of Category 2 emergency patients are seen within 10 minutes of triage • 75% of Category 3 emergency patients are seen within 30 minutes of triage • 70% of Category 4 emergency patients are seen within 1 hour of triage • 70% of Category 5 emergency patients within 2 hours of triage • 80% of emergency patients have a length of episode of four (4) hours or less.

4.8.1.2 Surgical Services • 94% of category 1 patients have required surgery within 30 days of being seen • 84% of category 2 cases patients have required surgery within 90 days of

being seen • 98% of urgency category 3 patients have required surgery within one (1)

year of being seen.

4.8.1.3 Ambulatory Care – Immunisation Nursing • 70% of community patients 65 years of age or older receive immunised

against influenza. • Inpatient Services • 99.9% of patient days are Staphylococcus aureus bacterial infection free.

4.8.1.4 Community Mental Health • 88% of patients are not readmitted to an Acute Psychiatric Unit within 28

days of discharge. 4.8.1.5 Dental • 100% of eligible population requiring general dental care are seen within 30 days

4.8.1.6 Hospital Management • 99% of actual budget equals the budget every month • 98.8% of the workforce is retained • 70% of the workforce is compliant with hand hygiene mandatory training • 80% of cases are coded within two (2) weeks of discharge and 100% of

remaining cases are coded within four (4) weeks of discharge • 100% of patient complaints are responded to within five (5) days of notice • 99% of payrolls are entered, authorise and submit payrolls every two (2) weeks • 100% of SAC 1 Clinical incidents are reported to the Clinical risk unit within

45 working days of the incident notification date.



4.8.2 Internal Interdependencies Listed below is a range of internal interdependencies between individual areas/departments within the Busselton Health Campus. For each of these dependencies, the nature (i.e. upstream [U] - the department depends on others, downstream [D] - others depend on the department or both [B] - departments depend on one another equally).

Adm

inis

tratio

n an

d M

edic

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ecor

ds

Ambulatory Care

Com

mun

ity M

enta

l Hea

lth

Engi

neer

ing

Emer

genc

y D

epar

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t General Ward

Hos

pita

l Man

agem

ent

Post

-Acu

te C

are

Ser

vice

Phar

mac

y an

d Su

pply

Perioperative Unit Support Services

Department Sub Unit Com

mun

ity N

ursi

ng

Allie

d H

ealth

Aged

Car

e S

ervi

ces

Inpa

tient

Med

ical

an

d N

ursi

ng C

are

Mat

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ty

Hos

pice

Ope

ratio

n Th

eatre

Cen

tral S

teril

isat

ion

Serv

ices

Dep

t.

Day

Sta

y U

nit

Food

Ser

vice

s

Laun

dry

Serv

ices

Truc

king

Ser

vice

s

Cle

anin

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rvic

es

Ord

erly

Ser

vice

s

Mor

tuar

y Se

rvic

es

Administration and Medical Records

D D D D U D D D D B D D D D D U D D

Ambulatory Care Community Nursing U U U U

U

U

Allied Health and continence nursing B B U D D D D U

U U D U

U

U

U U

Aged Care Services U U U B B D

Community Mental Health U B B

U B B B

B U

U

Engineering D D D D D D D D B D D D D D D D D D D D Emergency Department U B B U B B B U B U B B U U U U U U

Wards General U B U B U B

D B B U U B B U U U U U U

Maternity U B U U B B B U U B U U U U U U

Hospice U U U U U U D B B U U U U U U U U

Continued…



Adm

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Ambulatory Care

Com

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Engi

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Emer

genc

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Hos

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Post

-Acu

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are

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Perioperative Unit Support Services

Department Sub Unit Com

mun

ity N

ursi

ng

Allie

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Aged

Car

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Inpa

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Med

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an

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are

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Serv

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Ser

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Mor

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Hospital Management B B B

Post-Acute Care Service U U B D D B U U U U

Pharmacy U D U D D D D B D D Supply B D D D U D D D D B U D U D D D D D D Surgical Services Operation Theatre B B U D B B U U B B B B

CSSD B B U D B U U B B B B Day Stay Unit B B U D B U U B B B B Support Services B D U D D D B D D D Dental U D U U U U U



4.9 Overall Business Continuity Priorities Maximum Tolerable Periods of disruption have been determined for each business function to prioritise the recovery and resumption of services / functions undertaken by the Busselton Health Campus. These are as follows:

Department Area Service / Activity MTPD Priority Emergency Department Triage 1 min 1

Emergency Department Resuscitation including trauma (1 and 2) 10 min 1

Engineering Responding to lift faults 30 min 1 Global Diagnostics On call reporting services 30 min 1


Emergency Telephone switchboard/communications (external including Code Brown)

30 min 1


Emergency Telephone switchboard/communications (internal i.e. activating Emergency Management Team)

30 min 1

Wards Inpatient medical and nursing care

Communicating with medical and nursing staff 1 hour 2

Wards Maternity Emergency Caesarean 1 hour 2

Wards Maternity Post natal care for mothers and newborns 1 hour 2

Wards Maternity Communicating with medical and nursing staff 1 hour 2

Wards Maternity Acute Antenatal care including health checks 1 hour 2

Global Diagnostics Reporting 1 hour 2

PathWest Specimen Collection 1 hour 2

PathWest Analysis 1 hour 2

Wards Maternity Post natal operative procedures 1 hour 2

PathWest Analysis 1 hour 2 Emergency Department Registration 2 hour 2


Wards Maternity Post natal operative procedures 1 hour 2


Wards Maternity Post natal operative procedures 1 hour 2 Emergency Department Registration 2 hour 2

Engineering Responding to essential service faults 2 hour 2

Engineering Responding to AC faults 2 hour 2

Engineering Respond to ventilation supply faults (includes exhaust air) 2 hour 2



Department Area Service / Activity MTPD Priority

Engineering Responding to nurse call bell system faults 2 hour 2

Engineering Responding to duress alarm faults 2 hour 2

Engineering Responding to CCTV system faults 2 hour 2

Engineering Responding to access control faults 2 hour 2

PathWest Provision of POC testing equipment 2 hour 2 Support Services Food services Food Delivery 2 hour 2

Support Services Food services Collection of soiled dishes and waste 2 hour 2

Wards Maternity Midwife review of ED presentations 4 hour 2 Ambulatory Care

Community Mental Health Acute Community Mental Health Services 4 hour 2

Emergency Department Acute care (3) 4 hour 2

Hospital Management Emergency Management

(response function) 4 hour 2

Support Services Food services Storage of food 4 hour 2

Global Diagnostics Screening 4 hour 2

Global Diagnostics Imaging Intensifier 4 hour 2

Global Diagnostics Mobile Imaging Unit- ED Theatre 4 hour 2

Global Diagnostics Interventional procedures 4 hour 2

Global Diagnostics OPG 4 hour 2

Global Diagnostics CT 4 hour 2

Global Diagnostics Plain films 4 hour 2

Global Diagnostics Ultra Sound (U/S) 4 hour 2

Wards Inpatient medical and nursing care

Reversed barrier nursing for immuno-suppressed patients 8 hour 2

Wards Hospice Palliative care (Acute Inpatient) 8 hour 2 Administration and Medical Records

Patient information data entry (WEBPAS) 12 hour 2

Wards Hospice Referral to other consultancy and allied services 1 day 3

Wards Inpatient medical and nursing care Acute medical 2 day 3

Hospital Management IProc finance (approving supply orders) 2 day 3



Department Area Service / Activity MTPD Priority Hospital Management Responding to Ministerial and Parliament

enquiries 2 day 3

Support Services Food services Ordering of supplies 2 day 3

Support Services Laundry services Supply Laundry 2 day 3

Support Services Laundry services Processing soiled laundry 2 day 3

Support Services Mortuary Services Dispatching cadavers 2 day 3

Ambulatory Care Allied Health In Patient Physiotherapy 3 day 3

Ambulatory Care Allied Health In Patient Speech Pathology 3 day 3

Engineering Maintain access control systems. 3 day 3 Post-Acute Care Service Onsite/area outpatient care 3 day 3

SJOG Renal Treatments (Dialysis) 3 day 3 Supply and Pharmacy Supply Iprocurement/stock/non stock requisition 3 day 3

Supply and Pharmacy Supply Imprest reads 3 day 3

Supply and Pharmacy Supply Imprest restocking 3 day 3

Supply and Pharmacy Pharmacy Maintain pharmacy stock 3 day 3

Supply and Pharmacy Pharmacy Imprest ordering 3 day 3

Supply and Pharmacy Pharmacy Non imprest ordering 3 day 3

Support Services Trucking Services

Soiled and clean supplies, Non-medical, CSSD, internal mail service to rural site/areas pickup and delivery

3 day 3

Support Services Cleaning services Waste management 3 day 3

Ambulatory Care Allied Health Non acute Community Mental Health

Services 4 day 3

Hospital Management Complaints management 5 day 3

Support Services Mortuary Services Storing cadavers 5 day 3

Wards Maternity Education and training for staff 1 week 4

Wards Hospice Education and training for nursing staff 1 week 4 Ambulatory Care Allied Health In Patient Occupational therapy 1 week 4

Ambulatory Care Allied Health Non Admitted Patient Physiotherapy 1 week 4

Ambulatory Care Allied Health Non admitted Patient Social work 1 week 4



Department Area Service / Activity MTPD Priority Emergency Department Short stay observation (post assessment

treatment and ongoing care) 1 week 4

Engineering Maintaining essential supply services (water, power, sewer, medical gases, and natural gases).

1 week 4

Engineering Maintain AC/ ventilation equipment. 1 week 4 Administration and Medical Records

Initiating patient flows (way finding) 1 week 4


Telephone switchboard/communications (routine communications) 1 week 4


Medical record tracking WEBPAS 1 week 4

Hospital Management Entering and Authorising Rosters (function,

regular) 1 week 4

Hospital Management Workplace Health and Safety (reporting,

investigations and corrective actions) 1 week 4

Hospital Management

Fleet Management (maintenance, management, servicing, cleaning, working alone)

1 week 4

PathWest Result generation 1 week 4

PathWest Outpatient Pathology collection 1 week 4 Supply and Pharmacy Pharmacy Custodian of S4R/ S8 keys 1 week 4

Support Services Cleaning services Ordering and distribution of cleaning

products 1 week 4

Ambulatory Care Allied Health In Patient Social Work 2 week 4

Wards Inpatient medical and nursing care Acute surgical (post-surgery 2 week 4

Wards Inpatient medical and nursing care Care awaiting placement 2 week 4

Ambulatory Care Nursing Community Child Health Services 2 week 4

Ambulatory Care Nursing In Patient Continence Services 2 week 4

Ambulatory Care Nursing Non Admitted Patient Continence Services 2 week 4

Ambulatory Care Nursing Immunisation Services 2 week 4

Ambulatory Care Allied Health In Patient Dietetic Services 2 week 4

Ambulatory Care Allied Health Non Admitted Patient Occupational Therapy 2 week 4

Ambulatory Care Allied Health Non Admitted Patients Speech pathology 2 week 4



Department Area Service / Activity MTPD Priority Hospital Management Security Coordination (patrols, response,

guarding) 2 week 4

Perioperative Unit Operating Theatres Perioperative care 2 week 4

Perioperative Unit CSSD Decontaminating surgical and medical

equipment 2 week 4

Perioperative Unit CSSD Sterilising surgical and medical equipment 2 week 4

Perioperative Unit CSSD Storing sterile non disposable equipment 2 week 4

Perioperative Unit DSU Pre admission processes for Elective Day

Surgery Procedures 2 week 4

Perioperative Unit DSU Emergency Bed Response 2 week 4

Supply and Pharmacy Supply Transport 2 week 4

Supply and Pharmacy Supply Other coastal site/areas 2 week 4

Supply and Pharmacy Pharmacy Transport 2 week 4

Supply and Pharmacy Pharmacy Receiving ordered supplies 2 week 4

Support Services Mortuary Services Receiving cadaver’s 2 week 4


Data entry (surgical wait list) 2 week 4


Account receivable( patient accounting, AA revenue, implant recoup)

3 week 4

Wards Inpatient medical and nursing care Paediatrics 1

month 5

Wards Hospice Palliative care specialists clinics 1 month 5

Ambulatory Care Nursing Enuresis Services 1

month 5

Ambulatory Care Allied Health Non Admitted Patient Dietetic Services 1

month 5

Ambulatory Care Allied Health In Patient Podiatry 1

month 5

Ambulatory Care Allied Health Non Admitted Patient Podiatry 1

month 5

Engineering Responding to internal lighting faults 1 month 5

Engineering Maintaining nurse call bell systems. 1 month 5

Engineering Maintaining duress alarm systems. 1 month 5

Engineering Maintain CCTV systems. 1 month 5



Department Area Service / Activity MTPD Priority

Engineering Maintaining external lighting. 1 month 5

Engineering Maintaining internal lighting. 1 month 5

Engineering Maintaining lift services 1 month 5


Account payable (VMP's, on call rosters, surgical assist, locum etc.)

1 month 5

Hospital Management Finances (budgets management, projections

reporting) 1

month 5

Hospital Management Implementing action plans from various

Audits 1

month 5

Perioperative Unit DSU Day infusion procedures (i.e. blood Irons,

transfusions and IV medications). 1

month 5

Supply and Pharmacy Pharmacy Distributes to wards (physical) 1

month 5

Support Services Cleaning services General hospital clean 1

month 5

Wards Maternity Booking Routine Antenatal care including health checks and education

1 month 5

Wards Inpatient medical and nursing care Education and training for staff 3

month 5

Engineering Maintain grounds (road sweeping, shrubbery)

3 month 5

Engineering Asset maintenance (i.e. , window cleaning, gutter cleaning, salt wash-downs, painting)

3 month 5

Hospital Management Performance management and development 3

month 5

Post-Acute Care Service Onsite/area telehealth support 3

month 5

Supply and Pharmacy Supply Receivable 3

month 5

Supply and Pharmacy Supply Returns 3

month 5

Supply and Pharmacy Pharmacy Return of expired Bunbury stock 3

month 5

Supply and Pharmacy Pharmacy Returns of stock to Bunbury pharmacy 3

month 5

Ambulatory Care Nursing School Health Services 3

month 5



4.10 People This section outlines the charter of the Emergency Management Team operating under this Business Continuity Plan, the teams structure, reporting relationships, roles and responsibilities and lists the contacts for key stakeholders.

4.10.1 Team Members

ROLE POSITION Regional Health Disaster Coordinator Regional Director or nominated proxy Tier 4 Manager Coastal Operations Manager Business Continuity Officer Coordinator of Nursing

After Hours Coordinator (Deputy) Communications Officer Administrations Coordinator

Emergency Department Reception Clerk (After hours)

Are Wardens Heads of department (e.g. Clinical Nurse Manager, Service Manager)



4.10.2 Structure and Reporting Relationships

The structured framework that provides the predetermined emergency response activities is based upon the Emergency Controller Emergency Management Team model. Figure 3 identifies the Emergency Management Team model and the reporting relationships of the team operating under this plan.

Business Continuity

Officer

Tier 4 Manager

Emergency Controller

Communications Officer

Area Warden

Business Continuity

Team Member

Department Business Continuity Team

Emergency Management TeamEmergency Management Team

Figure 3: Business Continuity response structure and report lines



4.10.3 Roles and Responsibilities

ROLE RESPONSIBILITIES

Regional Health Disaster Coordinator

• Ensures that the Business Continuity Plan is approved • Ensure information about a disaster or a critical emergency is

escalated to the Chief Operating Officer - Operations • Provide and manage resources to support business continuity • Attend (or nominate a proxy) District Emergency Management

Committee meetings.

Tier 4 Manager

• Ensure that a Business Continuity Plan is prepared and endorsed

• Distribute Business Continuity Plans. Where appropriate, to communicate plans to Local Emergency Management Committees

• Ensure that, a person is delegated to command and control specific emergencies at all times

• Determine the location of the Local Emergency Operations Centre

• Ensure the Business Continuity Plan is exercised at least annually

• Ensure that resources are made available for an emergency response

• Ensure the Business Continuity Plan is maintained • Ensure that all physical areas are the responsibility of a

nominated person during an emergency • Ensure that all new, temporary and casual staff or contract

labour are familiarised with emergency management arrangements

• Maintain communication with the Regional Health Disaster Coordinator and the Business Continuity Officer and other key stakeholders

• In the event that critical business functions are disrupted, activate and proceed to the Local Emergency Operations Centre and control the overall response

• If necessary, activate the Emergency Planning Committee • Ensure debriefs occur after activation or exercising of plans.



ROLE RESPONSIBILITIES

Business Continuity Officer

• Maintain a register of Business Continuity Team members • Replace Business Continuity Team members when a position

becomes vacant • Conduct regular Business Continuity exercises • Attend training and emergency response exercises as required

by the Coastal Emergency Planning Committee • Ensure Business Continuity Team identification is available • Command and control the operational response to disruptions to

critical business functions • Ascertain the nature of the disruption and take appropriate

actions to restore infrastructure and essential services • Ensure key stakeholders have been notified (including third

parties such as the emergency services) • Monitor the progress of response actions and ensure all actions

are being recorded • Ensure the emergency services/essential service providers are

appropriately briefed on the situation upon their arrival to site/area

• Notify occupants to return the facility/their area when disruptions have been resolved

• Organise a debrief with all key stakeholders • Compile a report for the Coastal Operations Manager on the

business continuity response.

Emergency Controller

• Communicate business continuity arrangements to area/department staff

• Ensure the availability of an Area Warden kit for the area of responsibility

• Attend training and emergency response exercises as required by the Coastal Emergency Planning Committee

• Maintain communications with the Emergency Controller and other key stakeholders

• Advise the Emergency Controller as soon as possible when critical business functions are or likely to be disrupted

• Compile a report for the Emergency Controller on the actions taken during the emergency response

• Attend debriefs as required by the Emergency Controller.

Area Wardens

• Ensure resources required for a continuity response are readily available

• Attend emergency response training as required by the Coastal Emergency Planning Committee

• Respond to disruptions as directed by the Business Continuity Officer

• Maintain communications with the Business Continuity Officer and other key stakeholders

• Attend debriefs as required by the Business Continuity Officer.



4.11 Contact Details 4.11.1 Supplier and Contractor Contact List

Name Position Phone Mobile Email

Activ Foundation 9754 2547

Air Conditioning MPM 92024666

ARM 93283666

ASP Security 0407 159 499

Australia Post Postal Manager Retail: Ian Kealy 9752 7120 [email protected]

Department of Housing and Works 1800 093 325

Chubb 9499 7800

City of Busselton 9781 0444

Community Justice 9753 7100

Coviedien 9349 8929

Department of Child Protection 9722 5000

1800 199 008

Department of Housing 9222 4666

Disability Services Commission 9426 9200


mailto:[email protected]



DPMU 9222 2437 9328 0553

Eclipse Security 08 9734 7770

Education Department 08 9264 4111

Global Diagnostics Australia 08 9753 6800 On Call

0447 617 928

Health Direct 1800 022 222

IT Helpdesk 1800 794 748

Invitro (CSSD Washers) 1300 552 003

Iron Mountain Customer Service 08 63507100

61 438 600 771

[email protected]

JNR Security 0419 949 812

Local Taxi

BUSSELTON: 131008 DUNSBOROUGH: 97568688

NETS WA 1300638792






PathWest 08 9754 6260 On Call 0427 370 007

Poison Toxicology Unit 131126

RFDS 1800625800

Richmond Fellowship 08 9350 8800

Rural Link 1800 552 002

Schneider 0438 886 283

SJA URGENT 000

SJA NON URGENT 13 12 33

SJOG Renal 9753 6240

Smith and Nephew 131360

Staples 1300 136 538

Bunbury Supply Dept. 97221443

Symbion 1300 773 000

Transpacific 13 13 39

WA Police NON URGENT 131444



4.11.2 Busselton Health Campus Disaster Phone Directory

All Emergency Code Calls – Dial 55 Switchboard – 9 (internal) or 9753 6000

Afterhours Coordinator – 6555

WebEOC log in: http://ww2.health.wa.gov.au/Corporate/Articles/U_Z/WebEOC

Busselton Contacts Phone Phone

KEY BUSSELTON CONTACTS Emergency Response Team DISASTER ROOMS NUMBERS

Afterhours Coordinator 6555 ED Disaster Room Numbers Security Officer Wireless 6089 ED Meeting Room, Cisco Phone 6059 PSA Roving, Level 1 6358 Last Resort phone 9751 2208 PSA Roving, Ground Floor 6359 Fax 9751 2271 Communications Officer 55 Executive Disaster Room Numbers

Medical Emergency Response Team Meeting Room 5, Cisco Phone 6385 Afterhours Coordinator 6555 Last Resort phone 9751 2350 ED Nurse Coordinator 6063 Operations Meeting Room Fax 9751 2270 ED Medical Coordinator 6062 Ward 1 Senior Medical Practitioner 6127

PSA Roving Ground Floor 6359 BACK UP PHONES Emergency Back-up Mobiles

Area Wardens, Cisco Phones Emergency Phone 1 0437 342 261 Ambulatory Care Reception 6018 Emergency Phone 2 0437 163 092 BHC Main Reception 6002 Emergency Phone 3 0437 268 398 Community Health Manager 6448 Emergency Phone 4 0437 099 781 ED Shift Coordinator 6063 Emergency Phone 5 0437 176 301 Executive Admin Assistant 6376 Emergency Phone 6 0437 206 540 Kitchen Wireless 6365 Managing Scientist in Charge 6267 Last Resort (Analogue) Phones

Maternity Shift Coordinator 6133 ED Meeting Room 9751 2208 Renal Shift Coordinator 6249 ED Reception 9751 2115 Senior Radiographer 6550 Main Reception 9754 2863 Support Services Manager 6360 Operations Meeting Room 9751 2350 Surgical Serv Clinical Nurse Manager 6162 Surgical Reception 9754 8991

Ward 1 Shift Coordinator 6121 Ward 1 9751 2385 Ward 2 Shift Coordinator 6221 Ward 2 9751 2017


http://ww2.health.wa.gov.au/Corporate/Articles/U_Z/WebEOC


Busselton Contacts Phone Phone Busselton Executive Operations Manager, Coastal 6371 Flow of inbound 55 calls:

Operations Manager, Coastal 0400 911 614 Between 07:00 & 23:00

Inbound 55 calls ring on the Switchboard Operator, Medical Records desk

District Manager, Busselton 6373 District Manager, Bsn Mobile 0417 948 738

Medical Director, Busselton 6375 Between 23:00 and 07:00 Inbound 55 calls ring on ED Reception Wireless

Medical Director, Bsn Mobile 0437 948 663

Busselton Clinical Nurse Managers During all hours

When the line is busy, or call is unanswered 55 calls will ring on

Afterhours Coordinator’s Wireless

Emergency Department 6061 Nurse Unit Manager Inpatients

6101

Maternity 6131 Surgical Services 6162

WACHS South West Contacts Role Phone Email Bunbury Hospital Afterhours Coordinator

9722 1262 [email protected]

Regional Disaster Contacts

Regional Disaster Coordinator 0407 988 161 [email protected] DoH, Disaster Preparedness and Management, On Call Duty Officer 9328 0553

WACHS Comms 6145 4166 [email protected]

South West Executive Contacts Regional Director 0407 988 161 [email protected] Regional Nurse Director 0427 900 951 [email protected] A/Director Corporate Services 0449 769 798 [email protected] Director Population Health 0429 684 236 [email protected] Regional Mental Health Manager 0417 947 227 [email protected] Director of Nursing and Midwifery 0427 900 951 [email protected] A/Regional Medical Director 0414 519 072 [email protected] Manager Aged Care 0429 103 370 [email protected] Manager Infrastructure & Support Services

0419 961 755 [email protected]

Operations Manager Bunbury Hosp 0408 219 331 [email protected] A/Operations Manager Inland 0400 977 431 [email protected] Operations Manager Inland 0408 421 536 [email protected] WACHS Disaster Coordinator Contact WACHS Chief Operations Officer

0419 942 104

[email protected]




















4.12 Continuity Arrangements This section outlines the framework for coordinating and controlling a response, details alternate site/areas where business functions may be carried out and resource requirements, identifies workarounds that may be implemented in the event of a disruption and describes the response actions to be implemented when critical business functions are disrupted or are likely to be disrupted for periods that exceed the tolerable time periods.

4.12.1 Coordination and Control Framework

The Busselton Health Campus coordination and control framework is based upon the Operations Manager managing with an effective span of control over five other senior managers tasked with specific responsibilities. The frame work is depicted in figure.

Communications Information Gathering and Planning

Support Sevices Business Management

Overall Control

Operations

Operations

Figure 4: Coordination and Control Framework

4.12.2 Overall Control

A key responsibility of the Operations Manager is in the planning for business continuity which is carried out at the Coastal Emergency Planning Committee.

4.12.3 Operations

This function is carried out by the Business Continuity Officer who is responsible for the operational response activities associated with the response strategy.



4.12.4 Information Gathering and Planning

This function is carried out by a senior Emergency Planning Committee delegate who is responsible for the gathering of information including the disruption, resources and required tasks. This functions interfaces with the Emergency Planning Committee in the preparation of measures to continue service.

4.12.5 Support Services

This function is carried out by the Busselton Health Campus Support Services Coordinator who is responsible for the site/areas logistics and general support services.

4.12.6 Business Management

This function is carried out by the Busselton Health Campus Business Manager who is responsible for tracking the costs of the disruption, the implementation of the response strategy, escalating extraordinary budget requests for sign off, purchasing additional equipment and supplies and coordinating the temporary cessation of non-essential supply lines and items.

4.12.7 Communications

This function is carried out by the Communications Officer and is responsible for ensuring communications follow the chain of command (as per chart 1) and coordinating business continuity communications as per section 4 – business continuity communications.

4.13 Alternate Site / Areas

The following site/areas may be used to support the resumption of critical business functions of the Busselton Health Campus: • South West Health Campus • Bunbury Tower • Busselton Corporate Offices (Fairbairn Road) • West Street Offices • Margaret River Hospital • Nannup Hospital • Geographe Leisure Centre.

Note: Alternate site/areas must be appropriately equipped to support the

resumption of critical business activities. This may require the redeployment of hospital resources.



4.14 Resource Requirements The types and quantities of resources required to support the activation and implementation of the Busselton Health Campus Business Continuity Plan are addressed in individual department/area Business Continuity Action Plans. However, for planning purposes, critical business activities have been mapped against essential services and their level of dependency identified. Note: Functions that have a level 4 or greater dependency on an essential service

to deliver their critical business activities should have contingency arrangements in place to avoid single points of failure. Functions that have less than a level 4 dependency on an essential service to deliver their critical business activity should have manual workarounds.

Function

Pow

er

Wat

er

Med

ical

ga

s LP

G

Gas

N

atur

al

Gas

ICT

A/C

Ven

tilat

ion

Suc

tion

Administration and Medical Records 5 1 1 1 1 5 4 4 1

Central Sterilisation Services Department 5 5 1 1 1 5 5 1 1

Cleaning 5 5 1 1 1 5 3 5 1 Community Nursing 5 4 1 1 1 5 5 3 1 Dental 5 5 1 1 1 5 3 5 5 Day Stay Unit 5 5 3 1 1 5 4 1 4 Dietetics 5 3 1 1 1 5 1 1 1 Emergency Department 5 4 4 1 1 5 4 4 4 Engineering 5 4 1 1 1 5 1 3 1 Food 5 5 1 5 5 5 3 5 1 General Ward 5 4 4 1 1 5 4 5 4 Hospice 5 4 4 1 1 5 4 1 4 Hospital Management 5 1 1 1 1 5 1 1 1 Laundry 5 5 1 1 1 5 3 5 1 Maternity 5 5 5 1 1 5 5 5 4 Mortuary 5 5 1 1 1 5 5 5 1 Occupational Therapy 5 4 1 1 1 5 3 1 1 Operating Theatres 5 5 4 1 1 5 5 5 5 Orderly 5 1 1 1 1 5 1 1 1 Podiatry 5 1 1 1 1 5 1 3 1 Pharmacy 5 3 1 1 1 5 4 4 1 Physiotherapy 5 4 4 1 1 5 4 4 2 Post-Acute Care Service 5 4 1 1 1 5 4 1 1 Social Work 5 1 1 1 1 5 1 1 1 Speech Pathology 5 4 1 1 1 5 4 3 2 Supply 5 3 1 1 1 5 1 4 1 Trucking 1 1 1 1 1 5 1 2 1



4.15 Workarounds and alternate solutions The following workarounds may be implemented to support the delivery of critical business functions in the event of an essential service disruption.

DISRUPTION WORKAROUND AND ALTERNATE SOLUTIONS

Air Conditioning

• Blankets • Natural ventilation • Manual cool down methods (ice packs, moist towels,

showers etc.)

Landline Communications

• Mobile Network • Last resort phones located in:

− Main Entry reception − ED reception − Primary and Secondary Local Emergency Operations

Centres − Ward 1 Staff Station − Ward 2 Staff Station − Surgical services.

• Runner system

Mechanical Ventilation • Natural ventilation methods (i.e. manually opening doors and windows)

Medical Gases • Bulk supply of portable medical gas bottles on hand

Mobile Telecommunications

• Land telecommunications system • Satellite phones • Runner system

Nurse Call Bell

• Unified devices • Mobile phones • Runners • Patient phones • Handbells • Increased staff surveillance / rounding

Paging Systems • SMS to mobile phones • Runners • Public Announcement System

Suction • Venturi Twin o Vac units at point of use • Electric portable suction unit

Water • Bulk supply of bottled water on hand Data Network (PC disruptions) • Various – department specific



4.16 Continuity Management Tasks

Listed below are the critical business functions for each area/department of the Busselton Health Campus and a set of high level continuity management tasks. The priority represents the preferred order (1 being the highest priority whilst 5 is the lowest) in which critical business functions should be resumed.

4.16.1 Emergency Department

Critical Business Function Priority Immediate Response Plan (0 – 7 days) Sustainable Response Plan (1 week and greater)

Triage 1 • Temporaily suspend the function (whole of site

disruption only) • Transfer the function to another suitable

site/area.

• Relocate resources to alternate site/area(s) to carry out the function.

Resuscitation including trauma (1 and 2) 1

• Decant priority patients to the Bunbury Hospital • Place ED on bypass • Transfer the function to other suitable sites.

• Relocate resources to alternate site(s) to carry out the function.

Registration 2 • Temporarily suspend the function • Transfer the function to another suitable

site/area (Redirect relatives/significant others.)


Acute care (3) 2

• Decant patients to another suitable site/area • Redirect incoming presentations to another

suitable site/area • Transfer the function to another suitable

site/area.


Fast track (4 and 5) 3

• Decant patients to another suitable site/area • Redirect incoming presentations to another

suitable site; or to local General Practices • Transfer the function to another suitable

site/area.


Short stay observation (post assessment treatment and on-going care)

4 • Decant patients under observation to another

suitable site/area; or discharge to home • Temporarily suspend short stay observation.




4.16.2 General Wards


Reversed barrier nursing for immune-suppressed patients 2

• Decant patients requiring reveresed barrier nursing to another suitable site/area.

• Temporarily suspend new admissions • Transfer the function to another suitable

site/area.


Acute Paediatric Care 3

• Decant patients requiring paediatric care to another suitable site/area.


site/area.


Acute medical care 3

• Decant patients to another suitable site/area or discharge home


site/area.

• Relocate resources to alternate site/area(s)) to carry out the function.

Acute Voluntary mental health care

• Decant patients to another suitable site/area. • Temporarily suspend new admissions • Transfer the function to another suitable

site/area.


Acute surgical (post-surgery) care 4

• Decant patients to another suitable site/area or where appropriate, discharge home

• Temporarily suspend new admissions and care.

• Transfer the function to another suitable site/area.


Continued…




Care awaiting placement 4 • Decant patients to another suitable site/area.

(i.e MPS or source respite care) • Temporarily suspend new admission and care.

• Transfer the function to another suitable site.


Paediatric care 5 • Decant patients to Bunbury Hospital or where

appropriate, discharge home. • Temporarily suspend new admissions and

care.

• Transfer the function to the Bunbury Hospital.


General rehabilitaion care 5 • Decant patients to another suitable facility or

where appropriate, discharge home. • Temporarily suspend new admissions and

care.

• Transfer the function to the Bunbury Hospital.


Non acute voluntary mental health care 5

• Decant patients to another suitable facility or where appropriate, discharge home.

• Temporarily suspend new admission and care.



Education and training for staff 5 • Temporarily suspend the function. • Transfer the function to another

educator within the WACHS-SW region.



4.16.3 Maternity

Critical Business Function Priority Immediate Response Plan (0 – 7 days) Sustainable Response Plan

(1 week and greater)

Emergency Caesareans 2

• Decant priority patients to the Bunbury Hospital • Redirect incoming presentations to Bunbury

Hospital • Transfer the function to other suitable

site/area(s).


Post natal care for mothers and newborns 2

• Discharge healthy mothers and newborns home • Decant mothers and newborns requiring care to

another suitable maternity unit • Transfer the function to another suitable site.


Acute Antenatal care including health checks 2

• Redirect health checks to another suitable maternity unit

• Transfer the function to another suitable unit.


Post natal operative procedures 2 • Transfer the function to the Bunbury Hospital • Relocate resources to alternate

site/area(s) to carry out the function.

Midwife review of ED presentations 2

• Redirect incoming presentations to Bunbury Hospital

• Transfer the function to Bunbury Hospital.


Birthing 3 • Relocate to an alternate site/area to deliver

imminent births (5-10minutes) • Transfer function to another suitable site/area(s).


Home visiting Service 3 • Transfer the function to another suitable maternity unit.


Education and training for staff 4 • Temporarily suspend education and training for

ward staff.

• Transfer education and training function to another educator within the WACHS-SW region.

Booking routine Antenatal care including health checks and education

5 • Temporarily suspend the booking routine antenatal care including health checks.

• Transfer the function to another maternity unit within WACHS-SW.



4.16.4 Hospice


Palliative care (Acute Inpatient) 2

• Decant acute inpatients to another facility within the WACHS-SW region (i.e. Bunbury Hospital or Margaret River Hospital palliative care)

• Temporarily suspend new palliative admissions • Transfer acute the function to the Bunbury or

Margaret River Hospitals.


Palliative care (Home visits) 3 • Transfer palliative home visits to regional palliative care team or local HACC services.


Referral to other consultancy and allied services 4 • Temporarily suspend referrals.

• Transfer the function to regional palliative care team or local HACC services.

Education and training for nursing staff 4 • Temporarily suspend education and training for

ward staff.

• Transfer education and training function to another educator within the WACHS-SW region.

Palliative care specialists clinics 5 • Temporarily suspend all palliative care

specialist clinics. • Transfer specialist clinics to the

regional palliative care team.

4.16.5 Operating Theatres Critical Business

Function Priority Immediate Response Plan (0 – 7 days)

Sustainable Response Plan (1 week and greater)

Surgical Procedures 4

• Temporarily suspend elective lists. • Temporariliy suspend new admissions. • Decant recovering patients to another

WACHS-SW facility within the region. • Transfer emergency surgery to Bunbury

Hospital.

• Transfer elective lists to other regional operating theatres (i.e. Margaret River, Collie, Bridgetown, Warren).




4.16.6 Central Sterilisation Services Department (CSSD)


Decontaminating surgical and medical equipment 4

• Temporarily suspend the function • Relocate resources to an alternate location to decontaminate surgical and medical equipment

• Transfer decontamination of third party equipment to Bunbury Hospital CSSD.

Sterilising surgical and medical equipment 4 • Temporarily suspend the function • Transfer the function to Bunbury Hospital

CSSD. Storing sterile non disposable equipment 4 • Temporarily suspend the function • Relocate resources to an alternate

location to carry out the function.

4.16.7 Day Stay Unit


Pre admission processes for Elective Day Surgery Procedures

4 • Temporarily suspend the function • Temporarily suspend the function.

Emergency Bed Response 4 • Temporarily suspend the function • Temporarily suspend the function.

Day infusion procedures (i.e. blood Irons, transfusions and IV medications).

5 • Temporarily suspend the function • Transfer the function to another suitable site/area.



4.17 Medical Imaging Medical imaging is carried out by Global Diagnostics Australia whose response plans are not addressed in the Busselton Health Campus Business Continuity Plan.

4.17.1 Pathology

Pathology is carried out by PathWest whose response plans are not addressed in the Busselton Health Campus Business Continuity Plan.

4.17.2 Supply


Iprocurement /stock / non stock requisition 2 • Temporarily suspend the function • Transfer the function to the WACHS-SW

regional supply manager.

Imprest reads 2 • Temporarily suspend the function • Transfer the function to the WACHS-SW regional supply manager.

Imprest restocking 2 • Temporarily suspend the function • Transfer the function to the WACHS-SW regional supply manager.

Supplying other coastal sites 4 • Temporarily suspend the function • Transfer the function to the WACHS-SW regional supply manager.

Receiving supplies 5 • Temporarily suspend the function • Transfer the function to the WACHS-SW regional supply manager.

Returning supplies to main depot 5 • Temporarily suspend the function • Transfer the function to the WACHS-SW

regional supply manager.



4.17.3 Pharmacy


Maintains pharmacy stock 2 • Temporarily suspend function. • Transfer the function to the WACHS-SW chief pharmacist.

Imprest ordering 2 • Temporarily suspend function. • Transfer the function to the WACHS-SW chief pharmacist.

Non imprest ordering 2 • Temporarily suspend function. • Transfer the function to the WACHS-SW Chief Pharmacist.

Custodian of S4R/ S8 keys 4 • Transfer the custody of S4R/S keys to WACHS-SW Chief Pharmacist.

• Transfer the custody of S4R/S keys to WACHS-SW Chief Pharmacist.

Receiving ordered supplies 4 • Temporarily suspend function. • Temporarily suspend function. Distributes to ward (physical) 5 • Temporarily suspend function. • Temporarily suspend function. Returning expired stock to Bunbury 5 • Temporarily suspend function. • Temporarily suspend function.

4.18 Renal Renal dialysis is carried out by St John of God whose response plans are not addressed in the Busselton Health Campus Business Continuity Plan.



4.18.1 Ambulatory Care


Acute Community Mental Health Services 2

• Transfer the function to another suitable site/area (i.e. Bunbury Community Mental Health, Margaret River Hospital or Acute Psychiatric Unit).

• Relocate resources to an alternate location (i.e. transportable on site) to deliver the service.

Community Child Health Services 4 • Temporarily suspend community child

health care. • Transfer the function to another suitable

site/area; or local general practices.

In Patient Continence Services 4 • Temporarily suspend inpatient continence nursing.


Non Admitted Patient Continence services 4 • Temporarily suspend inpatient

continence nursing.

• Transfer the function to another suitable site/area; or

• Relocate resources to an alternate location to deliver the service.

Immunisation Services 4 • Temporarily suspend immunisation nursing.

• Transfer the function to another suitable site/area, or

• Relocate resources to alternate location to deliver the service.

Enuresis Services 5 • Temporarily suspend enuresis services.

• Transfer the activities to another suitable site/area, or

• Relocate resources to alternate location to deliver the service.

School Health Services 5 • Temporarily suspend school health

nursing. • Transfer the function to another suitable

site/area.



Allied Health Priority Immediate Response Plan (0 – 7 days) Sustainable Response Plan (1 week and greater)

In Patient Physiotherapy 3 • Temporarily suspend function. • Relocate resources to deliver the service.

In Patient Speech Pathology 3 • Temporarily suspend the function. • Relocate resources to deliver the service.

Non Acute Community Mental Health Care 3

• Temporarily suspend the function. • Relocate resources to an alternate location (i.e. LAMP Inc., General Practices or clients home; or

• Where face to face interactions are not essential deliver service via teleconference.

In Patient Social Work 4 • Temporarily suspend the function. • Relocate resources to deliver the service.

In Patient Occupational Therapy 4 • Temporarily suspend the function • Relocate resources to deliver the

service.

Non Admitted Patient Physiotherapy

4

• Temporarily suspend non admitted patient physiotherapy (including paediatrics).

• Transfer non admitted patient physiotherapy to another physiotherapist unit; or a local provider; or

• Relocate resources to an alternate site/area to deliver non admitted patient physiotherapy.

Non Admitted Patient Social Work 4

• Temporarily suspend the function. • Transfer the function to another suitable site/area or

• Relocate resources to an alternate site/area to deliver the service.



Allied Health Priority Immediate Response Plan (0 – 7 days) Sustainable Response Plan (1 week and greater)

Inpatient Dietetic Services 4 • Temporarily suspend the function. • Relocate resources to deliver the service.

Non Admitted Patient Occupational Therapy 4

• Temporarily suspend the function. •

• Transfer the function to another suitable site/area; or local occupational therapist; or

• Relocate resources to another facility to carry out the function.

Non Admitted Patients Speech Pathology 4

• Temporarily suspend non admitted speech pathology.

• Transfer the function to another suitable site/area or

• Relocate resources to an alternate site to deliver the service.

Non Admitted Patient Dietetic Services 5

• Temporarily suspend the function. • Transfer the function to another suitable site/area or

• Relocate resources to carry out the function.

In Patient Podiatry 5 • Temporarily suspend in patient and non-admitted patient podiatry.

• As per minimum level of service.

Non Admitted Patient Podiatry 5 • Temporarily suspend in patient and

non-admitted patient podiatry. • Transfer the function to another suitable

site/area; or a local provider; or • Relocate resources to carry out the

function.



4.18.2 Outpatient Clinics

Critical Business Function Priority Immediate Response Plan (0 – 7 days) Sustainable Response Plan

(1 week and greater) Geriatric 4 • Temporarily suspend the function. • Transfer the function to another suitable site/area Orthopaedic 4 • Temporarily suspend the function. • Transfer the function to another suitable site/area Urology 4 • Temporarily suspend the function. • Transfer the function to another suitable site/area Gynaecology 4 • Temporarily suspend the function. • Transfer the function to another suitable site/area Ophthalmology 4 • Temporarily suspend the function. • Transfer the function to another suitable site/area Audiology 4 • Temporarily suspend the function. • Transfer the function to another suitable site/area Psychology 4 • Temporarily suspend the function. • Transfer the function to another suitable site/area General medical 4 • Temporarily suspend the function. • Transfer the function to another suitable site/area

4.18.3 Post-Acute Care Service


Onsite Post-Acute care 2

• Decant patients requiring complex wound dressings and/or IV antibiotic administration to another area/department within the WACHS-SW region.

• Transfer the activity to another suitable site/area or General Practices.


Offsite Post-acute care 2 • Transfer the function of off site/area Post-Acute care to a third party provider (e.g. Silver Chain).


Onsite outpatient care 3 • Transfer the function to another suitable site/area or General Practices.


Onsite telehealth support 5 • Temporarily suspend on site/area telehealth support. • Relocate resources to an

alternate site/area to carry out the function.



4.18.4 Dental


Emergency dental care 3 • Redirect patients to Bunbury Hospital or

participating private practices within the Busselton area.

• Relocate resources to an alternate location to carry out the function.

General dental care. 4 • Temporarily suspend the function. • Relocate resources to carry out the function.

4.18.5 Administration and Medical Records


Controlling and coordinating external emergency communications (i.e. Code Brown)

2 • Divert external emergency calls to

another switchboard within the WACHS-SW region (i.e. Bunbury Hospital, Margaret River Hospital).


Controlling and coordinating internal emergency communications (i.e. activating Emergency Management Team)

2 • Divert internal emergency

communications to another phone/switchboard within the BHC or WACHS-SW region.


Entering patient information into WEBPAS; 2 • Transfer the function to another suitable

site/area. • Relocate resources to carry out the

function. Providing information and way finding 4 • Temporarily suspend the function. • Relocate resources to carry out the

function.

Controlling and Coordinating routine communications; 4 • Temporarily suspend the function.

• Divert routine calls to another switchboard within the WACHS-SW region.

Continued…




Tracking medical records via WEBPAS 4 • Temporarily suspend the function. • Where requested, initiate manual (i.e.

tracer card system).

Entering surgical wait list data 4 • Temporarily suspend the function. • Relocate resources to carry out the function.

Sorting/processing mail 4 • Temporarily suspend the function.

• Transfer the function to another suitable unit, or


Receiving account payments (patient accounting, AA revenue, implant recoup)

4 • Temporarily suspend the function.

• Transfer the function to another suitable unit, or


Paying accounts (Visiting Medical Practitioners, on call rosters, surgical assist, locum etc.)

5 • Temporarily suspend the function

• Transfer the function to another suitable unit (i.e. Bunbury finance, West street finance).


Managing cash, patient valuables and lost property. 5 • Temporarily suspend the function. • Relocate resources to carry out the

function.



4.18.6 Hospital Management


Emergency Management (response function) 2

• Relocate to the Regional Emergency Operations Centre (REOC) to manage the emergency.

• As per immediate response plan

Iprocurement finance (approving supply orders) 3

• Transfer the function another manager with at least equal delegations (as per vacation rules).


Responding to Ministerial and Parliament enquiries 3 • Transfer the function to another senior

manager. • Relocate resources to carry out the function.

Complaints management 3 • Transfer the function to another senior manager. • Relocate resources to carry out the function.

Entering and Authorising Rosters (function, regular) 4 • Transfer the function to another senior

manager. • Relocate resources to carry out the function.

Workplace Health and Safety (reporting, investigations and corrective actions)

4 • Transfer the function to another senior manager. • Relocate resources to carry out the function.

Infrastructure, facility and fleet Management (maintenance, management, servicing, cleaning, working alone).

4 • Transfer the function to another suitable unit. • Relocate resources to carry out the function.

Security Coordination (patrols, response, guarding) 4 • Transfer the function to another suitable

unit. • Relocate resources to carry out the function.

Finances (budget management, projections reporting) 5 • Temporarily suspend the function. • Relocate resources to carry out the function.

Implementing action plans from various Audits 5 • Temporarily suspend the function. • Relocate resources to carry out the function.

Performance management and development 5 • Temporarily suspend the function. • Relocate resources to carry out the function.



4.18.7 Engineering Department


Responding to lift faults 1 • Transfer the function (people caught in side) to lift technician. • As per minimum level of service.

Responding to essential service faults. 2

• Transfer the function to another engineering department within the WACHS-SW region.

• Transfer the function to a preferred contractor, or


Responding to AC faults 2 • Transfer the function to another

engineering department within the WACHS-SW region.


• Relocate resources to carry out the function. Respond to ventilation supply faults (includes exhaust air)

2 • Transfer the function to another




Responding to nurse call bell system faults. 2




Responding to duress alarm faults. 2




Responding to CCTV system faults 2




Responding to access control faults. 2




Responding to external lighting faults 3






4.18.8 Hospital Management

Critical Business Function Priority Immediate Response Plan (0 – 7 days)


Emergency Management (response function) 2

• Relocate to the Regional Emergency Operations Centre (REOC) to manage the emergency.

• As per immediate response plan

Iprocurement finance (approving supply orders) 3

• Transfer the function another manager with at least equal delegations (as per vacation rules).


Responding to Ministerial and Parliament enquiries 3 • Transfer the function to another

senior manager. • Relocate resources to carry out the function.

Complaints management 3 • Transfer the function to another senior manager. • Relocate resources to carry out the function.

Entering and Authorising Rosters (function, regular) 4 • Transfer the function to another

senior manager. • Relocate resources to carry out the function.

Workplace Health and Safety (reporting, investigations and corrective actions)

4 • Transfer the function to another senior manager. • Relocate resources to carry out the function.

Infrastructure, facility and fleet Management (maintenance, management, servicing, cleaning, working alone).

4 • Transfer the function to another suitable unit. • Relocate resources to carry out the function.

Security Coordination (patrols, response, guarding) 4 • Transfer the function to another

suitable unit. • Relocate resources to carry out the function.

Finances (budgets management, projections reporting)

5 • Temporarily suspend the function. • Relocate resources to carry out the function.

Implementing action plans from various Audits 5 • Temporarily suspend the function. • Relocate resources to carry out the function.

Performance management and development 5 • Temporarily suspend the function. • Relocate resources to carry out the function.



4.18.9 Engineering Department


Responding to lift faults 1 • Transfer the function (people caught in side) to lift technician. • As per minimum level of service.

Responding to essential service faults. 2




Responding to AC faults 2 • Transfer the function to another



• Relocate resources to carry out the function. Respond to ventilation supply faults (includes exhaust air)

2 • Transfer the function to another




Responding to nurse call bell system faults. 2




Responding to duress alarm faults. 2




Responding to CCTV system faults 2




Responding to access control faults. 2


• Transfer the function to a preferred contractor; or


Responding to external lighting faults 3


• Transfer the function to a preferred contractor; or

• Relocate resources to carry out the function. Continued…





Maintain access control systems. 3


• Transfer the function to a preferred contractor; or • Relocate resources to carry out the function.

Maintaining essential supply services (water, power, sewer, medical gases, and natural gases).

4 • Temporarily suspend essential supply service maintenance.


Maintain AC/ ventilation equipment. 4 • Temporarily suspend

AC/ventilation maintenance. • Transfer the function to a preferred contractor; or • Relocate resources to carry out the function.

Responding to internal lighting faults 5 • Temporarily suspend responding

to internal lighting fault. • Transfer the function to a preferred contractor; or • Relocate resources to carry out the function.

Maintaining nurse call bell systems. 5 • Temporarily suspend nurse call

bell maintenance. • Transfer the function to a preferred contractor; or • Relocate resources to carry out the function.

Maintaining duress alarm systems. 5 • Temporarily suspend duress

alarm maintenance. • Transfer the function to a preferred contractor; or • Relocate resources to carry out the function.

Maintain CCTV systems. 5 • Temporarily suspend CCTV maintenance.


Maintaining internal lighting. 5 • Temporarily suspend internal lighting maintenance.


Maintaining lift services 5 • Temporarily suspend lift maintenance.


Maintain grounds (road sweeping, shrubbery) 5 • Temporarily suspend grounds

maintenance. • Transfer the function to a preferred contractor; or • Relocate resources to carry out the function.

Asset maintenance (i.e. window cleaning, gutter cleaning, salt wash downs, painting)

5 • Temporarily suspend asset maintenance.




4.18.10 Support Services


Linen Services

Collection of soiled laundry 3

• Transfer the activity to another suitable site/area.

• Transfer the function to a laundry contractor within the Busselton area.


Supply clean linen 3




Processing soiled linen (washing, drying and folding) 3




Cleaning and Waste Management

Ward cleaning 3 • Temporarily suspend the function. • Transfer the function to a cleaning contractor within the Busselton area.

Clinical waste management 3 • • Temporarily suspend the function.

• Transfer the function to a cleaning contractor within the Busselton area.

General waste management 3 • Temporarily suspend the function. • Transfer the function to a cleaning contractor within the Busselton area.

Ordering and distribution of cleaning products 4 • Temporarily suspend the function. • Transfer the function to a cleaning

contractor within the Busselton area.

General hospital clean 5 • Temporarily suspend the function. • Transfer the function to a cleaning contractor within the Busselton area.

Continued…





Food Services

Delivering meals to patients 2 • Transfer the function to another suitable site/area.

• Transfer the function to a catering company within the Busselton area.

Collecting, transporting and cleaning soiled dishes and waste 2 • Transfer the function to another

suitable site. • Transfer the function to a catering company

within the Busselton area

Storing food 2 • Transfer the function to another suitable site/area. • Relocate resources to carry out the function.

Producing meals 3 • Transfer the function to another suitable site/area.

• Transfer the function to a catering company within the Busselton area.

Ordering and receiving food supplies 3 • Temporarily suspend the function. • Relocate resources to carry out the function.

Orderly Services

Transferring and handling patients 3 • Transfer the function to another suitable site/area.


Mortuary Services

Coordinating Cadaver Viewings 3 • Transfer the function to another suitable site/area.


Dispatching Cadavers 3 • Transfer the function to another to another suitable site/area.


Storing Cadavers 3 • Temporarily suspend the function.

• Transfer the function to local contractor • (e.g. Barrett and Son).

Receiving Cadavers (within the Busselton Health Campus or the community) 4 • Temporarily suspend the

function. • Transfer the function to local contractor • (e.g. Barrett and Son).

Trucking Services Trucking freight (soiled and clean supplies, Non-medical, surgical equipment for CSSD, internal mail service) to other coastal sites (pickup and delivery).

3 • Transfer the function to a local

courier company. • Hire an alternate truck.



4.19 Business Continuity Communications This section outlines the communications requirements following the activation of the Business Continuity Plan.

4.19.1 Authorisations

The WACHS Media Coordinator or the WACHS - South West Coordinator Executive Services (CES) are responsible for communicating Business Continuity arrangements to the Naturalist district and surrounding communities. For business continuity situations only, the following positions are authorised to issue business continuity communications on behalf of the Busselton Health Campus.

ROLE AUTHORITY

Tier 4 Manager

• Issue business continuity communications to the Regional Health Disaster Coordinator, WACHS-SW Executive and the Coastal Emergency Planning Committee.

• Issue business continuity communications to the WACHS media Coordinator or the WACHS-SW Coordinator of Executive Services.

• Provide updates to the Emergency Controller. • Where requested by the Media Coordinator, information to

the media. Emergency Controller

• Issue business continuity communications to Area Wardens. • Provide updates to Area Wardens.

Communications Officer • Provide updates.

Area Warden

• Issue business continuity arrangements to Business Continuity Team members, area patients, staff, visitors, families, next of kin and suppliers.

• Provide updates.

4.19.2 Continuity Messages

4.19.2.1 Protocols Disruptions or likely disruptions of/to critical business functions shall be reported to the Emergency Controller as soon reasonable practicable. The Emergency Controller will assess the Maximum Tolerable Period of Disruption and advise the Tier 4 Manager if there is a business continuity concern. Where a business continuity response is required (i.e. Maximum Tolerable Period of Disruption is exceeded or is likely to be exceeded), the responsible authority will arrange for the release of a message.



4.19.3 Communication Means

The following means are available for communicating business continuity messages in the event or likely event of a disruption to a critical business function. A single or a combination of means may be used.

COMMUNICATION

MEANS DETAILS

Global Email

Global emails should be sent as soon as reasonably practicable after the need for business continuity communications has been identified. Global emails should be used in combination with other communication means. Global emails should direct people to the WACHS-SW home page for further updates.

Email to EMT members

Emails targeted to Emergency Management Team members to advise them the response stage and the situation.

Business Continuity Page

A business continuity page should be sent to the Emergency Management Team and across the campus when fast communication is required.

Land line/DECT phones/Mobile Phones

A campus wide voicemail message may be released when employees have limited email and paging access.

WACHS-SW home page

A section on the WACHS-SW homepage will be designated to provide business continuity information. The WACHS-SW home page will be the primary source of information once the initial round of messages has been released.

WEBEOC Business continuity messages may be communicated by WEBEOC. The Tier 4 Manager will liaise with the DPMU so that they may initiate messages.

Public Announcement System

The Emergency Controller will be able to access the PA system. The PA system will allow a public address on the continuity response across the campus.

Warden Intercommunications Point Phones.

The Emergency Controller will be able to access the Warden Intercommunications Point (WIP) phones to communicate verbal messages directly to the Area Warden.



4.19.4 Continuity Message Content

The Busselton Health Campus emergency communications strategy focuses on providing and receiving information relating to the business continuity response.

STAKEHOLDER INFORMATION PROVIDED INFORMATION NEEDED

RHDC, Tier 4 Manager, Emergency Controller

• What has happened and how • What is being done to fix it • What are the impacts on

critical business functions • When will normal capability

be restored

• What has happened and how • What is being done to fix it • What are the impacts on

critical business functions • When will normal capability

be restored

Employees • The impact of the event • Current operational capability • Workarounds

• What has been disrupted and why

• What will happen in the future • Where are resources

available

Patients

• That an event has occurred • Impact on service to them • Alternate service delivery

arrangements

• What is the impact on patient safety

• How long is the service to be disrupted

• Will compensation need to be made

Next of Kin, Families and Visitors

• The extent of the event • Their family involved • Access to counselling

services

• What has happened • Who are involved (patients,

staff and/or visitors) and are they safe

• How could the disruption happen again

Media

• That an event has occurred and what has happened

• Operational status • Measures in place • Impacts

• What has happened and how • Can it happen again • Similar events that have

happened previously

Suppliers

• That the event has occurred • Supply requirements changes • Alternate arrangements to

order and receive supplies • Alternate arrangements for

account payments

• Changes to supply requirements

• Current inventory and holding time

• Likely duration of supply impacts

• Compensation under contractual conditions

Regulators • What has happened and how • What is being to fix it • Preventative measures

• What has happened and how • What is being done to fix it • Preventative measures • Non-compliance issues



4.19.5 Levels of Notification The Busselton Health Campus will normally be notified on the continuity response as per the stages of activation and stand down. Refer to section 0.7.1. for details. 4.19.6 Paging Message Guidelines

STAGE MESSAGE

Alert Possible business disruption < insert function disrupted and location >.

Response Confirmed business disruption < insert function disrupted and location >.

Stand down All clear - business disruption < Insert function disrupted and location >.



4.19.7 Tier 4 Manager Business Continuity Checklist

Position: Tier 4 Manager Action Card 1

Reporting to: Regional Health Disaster Coordinator Time Sign

On Alert

Conduct initial briefing with the Emergency Controller. Ascertain the nature of the disruption and the likely Maximum Tolerable Period of Disruption for the affected area(s)

Notify the Regional Health Disaster Coordinator & DoH Duty Officer Consider the activation of the Local Emergency Operations Centre and Web EOC

Pre warn Coastal Emergency Planning Committee Members. Establish communications protocols.

Pre warn other key site/area (e.g. Bunbury Hospital) and other key agencies (SJA, WA Police etc.). Establish communications protocols.

Ensure actions are being logged. Set up cost centre for emergency expenditure. Arrange for funds to be made available for continuity purposes. Ensure rotation of team members if the response is likely to exceed 24 hours.

Establish contact with WACHS Media Coordinator on (08) 9222 6499 or WACHS Communications via the WACHS – South West Coordinator Executive Services (CES) and advise of the situation.

Coordinate internal communications to staff with corporate communications.

Set up media briefing room. Draft/vet media releases. Monitor media coverage and media interest in the Busselton Health Campus, including social media.

Prepare alternate site/areas for occupation.





Stand by

Occupy and commission the Local Emergency Operations Centre (LEOC).

Set up a schedule and agenda for check point Emergency Planning Committee meetings.

Activate the Coastal Emergency Planning Committee. Determine at other site/areas:

a) Medical/nursing staff availability. b) Current hospital activity. c) Bed availability. d) Theatre availability

Provide a SITREP to the Regional Health Disaster Coordinator. Set up cost centre for emergency expenditure. Account for all people and determine the whereabouts of missing persons.

Coordinate the hiring of contractors, temporary staff and volunteers. Confirm the number and extent of casualties. Ensure coordinated care for the injured and determine the need to notify families.

Participate in local LEMC and DEMC briefings Arrange for emergency transportation, food and accommodation.

Allocate a single point of contact for all emergency supply requests. Arrange for the procurement of emergency office supplies. Liaise with the WACHS-SW Infrastructure Manager. Liaise with the WACHS-SW Facilities Manager. Ensure essential service providers are been communicated with. Work with essential service providers to restore services. Arrange for an increased security presence.





Response

Liaise with the Emergency Controller, Emergency Planning Committee members and commanders from other agencies.

Invoke continuity response plans as required. Maintain communications with the Regional Health Disaster Coordinator. Provide SITREPS.

Monitor status of business continuity efforts. Coordinate the redeployment of resources to other suitable site/areas.

Monitor and keep track of all emergency expenditure. Manage emergency disbursement of funds. Coordinate repatriation. Monitor ongoing whereabouts of patients and employees. Ensure emergency assistance is provided to employees families (e.g. child care, aged care, accommodation, transportation).

Respond to media enquiries. Coordinate media briefings and press conferences. Monitor and report on the status of the infrastructure and the essential services.





Stand down

Liaise with the Emergency Controller, Emergency Planning Committee members and commanders from other agencies

Instruct the Emergency Controller to stand down Business Continuity Teams

Coordinate incident debriefing processes Report and investigate and develop and implement corrective actions Coordinate insurance claims Participate in damage assessment Prepare for long term recovery (repairs, reconstruction, relocation planning, restoration of essential services)



4.19.8 Maps and Drawings

The Busselton Health Campus is made up of a number of structures where critical business functions are carried out. The following site/area maps provide a high level look of these structures and their geographic relationships to one another.

Administration

Hospital ManagementEmergency Department

Medical Records

Pathology

Pharmacy

Medical Imaging

Engineering Clinical Waste Management

Linen Service

s

Outpatients

Continence and Dietetics

Food Services

Ambulatory Care

Renal

MAIN ENTRY

Supply

Figure 6: Ground floor infrastructure relationships

Operating Theatres

Day Stay Unit

Day Stay Unit

Ward

Ward

1

1

MaternityMaternity

LIFT ENTRY

LIFT ENTRY

Hospice

Hospice

Ward

Ward

2

2

Dental

Dental

CSSD

Figure 7: Level 1 infrastructure relationships


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