code yellow – business continuity plan · a business continuity plan (bcp) is, in effect, a...

Date of Last Review: August 2017 of 21 Date Next Review: August 2017

WACHS GOLDFIELDS Leonora Community Health

Code Yellow – 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 Hospital Emergency/Disaster Procedures, 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. Recommended: Alicia Michalanney Director Population Health Date: 10 August 2017 Endorsed: Carol Erlank A/Regional Director

WACHS Goldfields Date: 17 August 2017

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

Contact: Director Population Health (A. Michalanney) Directorate: Operations TRIM Record # ED-CO-15-3410

Version: 2.00 Date Published: 22 August 2017 Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.

Effective: 17 August 2017

Business Continuity Plan – Leonora Community Health


DISTRIBUTION LIST This plan has been distributed to the following:

Name Organisation Position/Function Alicia Michalanney WACHS Goldfields Director Population Health Karine Miller WACHS Goldfields Coordinator Community Nursing Cheryl Liddiard WACHS Goldfields Community Nurse Manager Kay Terry WACHS Goldfields Business Manager 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. Hospital health coordinator A Hospital Health Coordinator (HHC) 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 HHC 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



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: o For which planning is possible. o Prioritised first by the impact of the disruption on service delivery (most

severe being the highest priority). • The plan integrates with the plans of 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 DPMU or SHICC with a request for assistance.

• Granting of a request for assistance 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 SHICC.

• 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 EQuIP 5 Standards and Guidelines,

Support Function Standard 2.1 & Corporate Function Standard 3.2 • Standards Australia, AS/NZS HB 292-2006, A Practitioners Guide to Business

Continuity Management. • Standards Australia, AS/NZS HB 221-2004, 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 Hospital Emergency Coordinator 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. HHC) 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

2. 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.

2.1 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 Western Australian Country Health Services (WACHS) of emergency management and/or business continuity plan activation.

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

2.2 Hospital Health Coordinator HHCs are responsible to the RHDCs during a MCI for:

• Provision of the hospital’s available resources. • Assuming overall command and control of the hospitals' general resources and

management of its responses. • Determining when it is appropriate to return to normal operations within the

hospital and managing the recovery phase. • Representing the hospital at Local Emergency Management Committee

(LEMC) meetings. • Maintenance of the hospital disaster plan (however titled). • Other duties, as requested.

2.3 Department heads/business managers and other nominated staff

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

2.4 All Staff (including contract and agency staff)

• Responsible for familiarising yourself with the local Business Continuity Plan for your 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.



3. 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.

4. 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 regional executive for endorsement. 5. 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;

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

More specialised and targeted training may be provided for Hospital Health Coordinators 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; • To 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; and • 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; and • In accordance with the Agency’s BCM maintenance programme.

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 Reviewed and updated every 3 months

6. CONTACT DETAILS A listing of key positions and their contact details are given in PART 3.



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.)



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



This BCP was designed to be used as a

quick reference in an Internal Emergency (Code Yellow)

Business Continuity Plan



NOTE: The Standard Operating Procedures for Hospital Wide Resource are to be used in conjunction with the specific procedures detailed below PROBLEM IMPACT CONTINGENCY ACTION/TASK WHEN RESPONSIBILITY Electricity Failure: Inability to supply normal services to sites Lighting Low light levels may result in OSH issues Refrigeration - Vaccines: Vaccines and other drugs may become unusable Air-conditioners/heaters Unable to regulate temperature

High

Determine period of outage Offer service to essential clients only. Close Health Centre- Leonora Use areas close to windows Use lanterns Use torches Identify Hazards Power off Monitor temperature of fridge; if nearing 8c transport vaccines to Leonora District Hospital with Tiny Tag® hours Keep fridges closed Use eskies and ice blocks. Vaccine fridge not on back-u power Use Natural ventilation Use Fans (if not power failure)

Ensure ongoing power status is communicated to all staff. Identify non-essential clients and reschedule appointments Ensure activated when power off Check adequacy of current emergency lighting. Windows clean Lanterns kept recharged. Charge on a three monthly basis. Located in small store room in reception area and child health clinic room. Keep corridors and work areas clear of all hazards Identify how long power likely to be off Tiny Tag® in fridge/eskies Ensure have supply of ice bricks and eskies. Monitor temperature Liaise with Leonora District Hospital for transfer and adequate storage facilities Ensure security monitoring company will phone CNM where there is a power outage Open windows/doors if able Determine priority sites for fans

Power failure

Leonora Community Nurse Manager Manager Physical Resources Regional Coordinator Community Nursing Engineering Immunisation Providers Community Nurse Community Nurse Manager



PROBLEM IMPACT CONTINGENCY ACTION/TASK WHEN RESPONSIBILITY Water Supply Failure: Infection control risks Loss of water supply for general use Loss of water for fire hose reels Drinking water

High

Determine length of disruption Alcohol l wipes/detergent wipes Antiseptic hand rubs Run on storage facilities if available Close health centre Use bottled water

Minimal use of bathrooms Ensure adequate supply Identify possible storage solutions. Source & cost alternate supplies Liaise with local council/utilities re emergency water supply Notify public Liaise with local fire Services Storage of bottled water with adequate stock

Loss of service

Manager Physical Resources Community Nurse Manager Coordinator Community Nursing

Sewerage: Loss of Sewerage to site Unable to dispose of waste products Infection control risks

Moderate

Refer to WA Water Authority Disaster Recovery Plan

Contact Water Corporation

Loss of Sewerage service

Manager Physical Resources Community Nurse Manager

Structure Damage: To building as a consequence of internal or external disaster Venue unable to be used or dangerous to enter

Extreme Refer to Emergency Procedures Manual –

• Code Red • Code Yellow • Cyclone • Earthquake • Flood

Alternative venues. Hire of other facilities for duration if applicable.

Transfer all staff to alternative locations. Secure all critical data and hardware.

Manager Physical Resources Community Nurse Manager



PROBLEM IMPACT CONTINGENCY ACTION/TASK WHEN RESPONSIBILITY ICT Issues: Failure of Information Technology WEBPAS AIR MS Outlook

High

Contact Help desk to log problem Use alternative methods of communication & documentation. Consider Keep manual record of data until able to be entered. Consider utilising Leonora District Hospital for webPAS data entry If computer working access authorisation file from computer hard drive. Record client details manually Use memos, faxes and manual distribution

Determine extent of ICT failure and implement ICT Recovery Plan Contact other sites and ask that communications be by phone. May need clerical support if down for some time Call back once system resumed giving appointments. Advise all staff

System failure

Manager ICT Community Nurse Manager

Failure Communications Systems Landline External Dial in failure Disconnection of service due to disruption to line or network Mobile – Disruption to network Fax/copier/scanner

High Can be related to power failure or other reasons

Ensure supply of mobile/satellite phones Notify public and other health centres Use landlines. Emails Aim to have at least one available or access Leonora

Emergency Coordinator identifies key staff. Use of Pool phones Liaise with local radio to make announcements Contact other sites and advise contact by email/mobile. Alternative call in for staff. Liaise with Leonora District Hospital to use facilities

System failure

Collaborate with Information services Community Nurse Manager Community Nurse



District Hospital machines Manager PROBLEM IMPACT CONTINGENCY ACTION/TASK WHEN RESPONSIBILITY Emergency Alarms – Duress alarms No knowledge of potential dangers/medical emergencies, Staff safety; Security company not alerted of smoke in building

High Ring 000 Fire evacuation procedures in Emergency procedures manual

Use runners Landline phone Review fire procedures and policy Educate staff

System failure

All staff

Staff Knowledge: Staff not knowing what to do in event of service disruption

Medium Educate staff on Business continuity plans Include in orientation

Location of plans Testing BCP periodically Location of equipment in event

All staff

PROBLEM IMPACT CONTINGENCY ACTION/TASK WHEN RESPONSIBILITY Vehicle/Transport loss

High Use alternate vehicle for transport of supplies such as car from Ware St or Leonora District Hospital

Identify vehicles available to hire/Borrow if required

Community Nurse Manager