code yellow - business continuity plan - derby hospital€¦ · a business continuity plan (bcp)...

Effective:

This information is available in alternative formats upon request

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Effective: 1 October 2014

WACHS KIMBERLEY

Derby Hospital

TITLE: 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 Bec Smith

Operations Manager Hospital Disaster Coordinator

Dated Approved

Kerry Winsor Regional Director, WACHS Kimberley

Dated VERSION CONTROL Amendment Entered Version

No. Page Number Date Signature Date


DISTRIBUTION LIST This plan has been distributed to the following:

Name Organisation Position/Function Kerry Winsor WA Country Health Service Regional Director - Kimberley Ben Watty WA Country Health Service A/Regional Facilities Manager -

Kimberley Dave Dench WA Police Officer in Charge - Derby Stephen Gash Shire Derby West Kimberley Chief Executive Officer Elsia Archer Shire Derby West Kimberley President – LEMC Chair 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.

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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.

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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

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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.

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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.

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• 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.

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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.

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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.

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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.

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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.

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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.

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

Contact: Operations Manager (B.Smith) Directorate: Operations TRIM Record # ED-CO-15-6124

Version: 1.00 Date Published: February 2014

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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.)

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7. Contingency Plans for Hospital Wide Resource Failure 7.1 Electricity Supply Failure Description: Failure of supply of electricity to whole hospital Impact Rating: Extreme Consequences of resource failure: Inability to supply normal services to all sites. Contingency strategy options: Emergency hospital power generation Consider service delivery levels, i.e. Revert to emergency cases only (i.e. no elective

procedures) Consider where patient cannot be discharged, the need to relocate patients to other hospitals Contact Hire companies for standby generators: see Location/Providers below. How long can operations continue in contingency mode: 2 - 3 Weeks – if hospital generator working 1 days – without power Trigger event/date to invoke the Business Continuity Plan: Electricity supply disruption/failure. Responsibility for implementing this strategy: District Manager Director of Nursing Maintenance Manager. Criteria for returning to normal operating mode: Resumption of electricity supply of a period greater than 15 minutes. Can this strategy be tested if so how: Yes, planned interruption to normal supply, run on emergency generation Location/Providers Coates Hire for generators: 9192 1080 Energy Applications – generator repair: 9192 1994 Broome Diesel and Hydraulic – generator repair mechanical: 9192 1330 Outback Electrical Derby: 0419 914 088 Wattnow Electrical Derby: 0488 410 497

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7.1.1 Electricity Supply Schedule Problem Impact Contingency Action/Task Start date End date Responsibility Electricity Failure Inability to supply

normal services to all sites

Emergency power generation

Ensure emergency generator supply to site

At point of failure 15 mins after resumption of normal power supply

Maintenance Manager

Ensure 4500 L fuel available on site

Continuous Continuous Maintenance Manager

Ensure essential appliances are connected to essential power outlets

At point of failure 15 mins after resumption of normal power supply

Maintenance Manager

Director of Nursing

Transfer patients out

Identify Patients for transfer

When contingency fails

Normal supply Senior Medical Officer

Director of Nursing Use alternate

emergency generator

Liaise with SES and Equipment Hire Company for priority use of generator

When contingency fails

Return to normal service

Operations Manager /Regional Director

Contingency failure

Close Hospital

Transfer patients out & close hospital

Contingency failure

Normal supply Operations Manager / Regional Director

Staff Education

Educate staff on contingency arrangements

On going Director of Nursing Maintenance

Manager


7.2 Air Conditioning Service Failure Description: Failure of air-conditioning not due to power failure in: 28 units in general ward 10 units in paediatric area 13 units maternity ward 9 units in kitchen and staff dining room Chilled water system to rest of Hospital Impact Rating: Very high Consequences of resource failure: Unable to regulate temperature and environment – patient and staff discomfort Contingency strategy options: Natural Ventilation – use fans and open windows Transfer emergency procedures to other facilities Discharge or transfer patients How long can operations continue in contingency mode: Operating Theatres – unable to continue. Rest of DHS – indefinite, depending on ambient conditions and comfort levels. Trigger event/date to invoke the Business Continuity Plan: Air Conditioning failure Responsibility for implementing this strategy: Operations Manager Director of Nursing Business Manager Maintenance Manager Criteria for returning to normal operating mode: Restoration of air conditioning function Can this strategy be tested; if so how: Isolate air conditioners Locations/Providers Maintenance Department ext 325 Maintenance Manager: 0429 109 010 Derby Refrigeration & Air-conditioning services: 9193 1729 QAL Refrigeration: 0418 873 593

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7.2.1 Air Conditioning Service Schedule

Problem Impact Contingency Action/Task Start date End date Responsibility Air Conditioning Failure Unable to

regulate temperature and environment

Instigate repair Call Maintenance Manager

When failure occurs

15 mins after Return of service

Director of Nursing Maintenance

Manager

Use natural ventilation / open windows / doors

Distribute fans from Maintenance Store

When failure occurs



Manager

Use fans Determine priority sites for use of fans

When failure occurs



Manager

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7.3 LPG Supply Description: Failure of Supply of Liquid Petroleum Gas due to no deliveries available to replenish supply.

LPG used in: Kitchen/Laundry Boiler Plant Room

Impact Rating Very High Consequences of resource failure: Unable to run cookers, dryers and hot water boiler. Can run on supply tanks for estimated 4 weeks. Contingency strategy options: Install temporary bottled supply to each outlet. Available from Kleenheat Gas: See Location/Providers below How long can operations continue in contingency mode: indefinitely Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Notification from supplier of loss of continuous supply Mechanical damage Regulator failure Responsibility for implementing this strategy: Operations Manager Director of Nursing Business Manager Maintenance Manager Criteria for returning to normal operating mode: Notification from supplier that supplies have returned to normal. Damaged equipment repaired or replaced Replentished supply Can this strategy be tested if so how: No Locations/Providers: Kleenheat Gas for bulk supplies 9192 3733 Kleenheat Gas for bottled supplies 9192 3733 Elders Derby: 9191 1808 Mobile: 0427 991 129

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7.3.1 LPG Supply Schedule Problem Impact Contingency Action/Task Start date End date Responsibility Bulk LPG Supply

Loss of bulk LPG supply

(and see other impacts below)

Emergency refill Or get bottled gas

delivered to site

Identify essential sites for gas rationing

Loss of supply Return of normal supply

Operations Manager Maintenance

Manager

Mechanical damage Regulator failure

Get bottled gas delivered to site

Re-order from Kleenheat Bulk

Order from Kleenheat local

When bulk gas is unavailable

Return of normal supply

Operations Manager Maintenance Manager

Unable to do use laundry dryer

Access other clothes drying facilities in town

Source alternative commercial dryers

Annual Return of normal supply

Support Services Manager

Rationalise use of linen

Without compromising infection control principles, reduce the amount of clean linen needed (e.g. Derby)

Annual agreement with Derby Health Services

When supply is compromised


Director of Nursing Support Services

Manager

Arrange for linen supplies from other regional health services

When previous contingencies fail



Unable to use stove in kitchen

Access other cooking facilities

Identify other means of cooking e.g. microwave

When supply is compromised


Maintenance Manager/ Cook

Identify other commercial kitchens in the area e.g. hotels, restaurants

Annual agreement with commercial kitchen

Normal supply Support Services Manager

Alternate food supplies Annual agreement with In-flight Catering



Purchase reheatable prepared meals

Source and cost meals



Staff Education Educate staff on contingency plans

Orientation Ongoing Staff Development Officer

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7.4 Medical Gases Description: Failure of bulk supply of Oxygen Failure of both bulk and reticulated bottled supply of Oxygen No Bottles Failure of bottled Nitrous Oxide. Impact Rating: Extreme Consequences of resource failure: Failure of the ongoing supply of medical gases by external suppliers would severely interrupt

the ability to conduct surgery and treat critically ill patients. Contingency strategy options: Stockpile gas supplies Have alternate suppliers established and contact numbers recorded. How long can operations continue in contingency mode: Failure of bulk supply: Indefinite depending on bottled supply Failure of bottled supply: Cannot continue Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Notification from supplier of loss of continuous supply Responsibility for implementing this strategy: Operations Manager Senior Medical Officer Director of Nursing Business Manager Maintenance Manager Criteria for returning to normal operating mode: Notification from supplier that supplies have returned to normal. Can this strategy be tested if so how: Test alarms and changeover methods Locations/Providers: BOC Gases, Streeter and Male Derby Building Supplies: 9191 1537 Mobile: 0419 950 903

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7.4.1 Medical Gases Schedule Problem Impact Contingency Action/Task Start date End date Responsibility Loss of medical gas supply Bottles only

Unable to supply medical gases for therapeutic use

Stockpile bottled supply of medical gases onsite

Increase stock for the cyclone season.

Impress system check weekly.

Ensure adequate local supplies

Identify priority sites for use of medical gases (incl. home O2 supply)

When supply compromised

Annual agreement with BOC to stockpile offsite

Return of supply

Director of Nursing Senior Medical Officer Support Services

Manager

Estimate usage of medical gases per week

Annually Senior Medical Officer Director of Nursing Maintenance Manager

Stockpile for at least two weeks without supply

Continuous Business Manager and Maintenance Manager

Distribute bottled gases to priority sites

When supplies are low

Normal supply

Business Manager and Maintenance Manager

Priority use of medical gases

Identify patients for priority use


Normal supply

Senior Medical Officer DON

Transfer patients out

Identify patients for transfer


Normal supply

Senior Medical Officer

Staff Education Educate staff on medical gas use and contingency

Orientation Ongoing Director of Nursing Senior Medical

Officers Business Manager

and Maintenance Manager

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7.5 Motor Vehicle Fuels Description: Loss of supply of Petrol and Diesel for Health Service vehicles. Impact Rating: Medium Consequences of resource failure: If suppliers have difficulty with pumps etc. this will impact on the Health Service. Contingency strategy options: Have all vehicles full when impending shortage is anticipated Transfer fuel from non essential to essential vehicles if supplies become severely diminished How long can operations continue in contingency mode: Indefinite with use of town suppliers – taxi etc. Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Loss of supply of Petrol/Diesel. Responsibility for implementing this strategy: Operations Manager Director of Nursing Business Manager Maintenance Manager Criteria for returning to normal operating mode: Notification from supplier that supplies have returned to normal. Can this strategy be tested if so how: No Locations/Providers: 4500 L Diesel tank on hospital campus BP Colac & Shell Service Stations: 0409 302 175 / 0400 218 835 BP Reliance: 9191 1383

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7.5.1 Motor Vehicle Fuels Schedule Problem Impact Contingency Action/Task Start date End date Responsibility Motor Vehicle Fuels Loss of supply,

inability to transport

Vehicles at capacity fuel level

Ensure all vehicles full of fuel

When there is an anticipated shortage

Return to normal supply

Business Manager

Ration fuel to essential vehicles

Transfer fuel to essential vehicles

Loss of supply Normal supply Operations Manager

Business Manager

Staff education Educate staff on contingency

Orientation Ongoing Business Manager

Cut back on transport

Identify essential vehicles

When there is an anticipated shortage

Return to normal supply

Business Manager

Use hospital diesel store

Ensure tank full Continuous Business Manager

Maintenance Manager

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7.6 Sewerage Description: Failure of sewerage disposal systems (town sewerage system) Impact Rating: Extreme Consequences of resource failure: Toilets, drains will stop flowing creating health hazard. Build up of waste will prevent patient treatment Contingency strategy options: Hire PortaLoos Relocate patients Contact local plumber Seek advice from local Government authority – Derby Shire Seek advice from Public Health Unit How long can operations continue in contingency mode: Less than 1 week Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Advice from local authority (local council) of failure of systems Responsibility for implementing this strategy: Operations Manager Director of Nursing Business Manager Maintenance Manager Criteria for returning to normal operating mode: Reinstatement of sewerage facilities/services Can this strategy be tested if so how: No Locations/Providers: Kimberley Hire Derby: 9191 1635 Mobile: 0419 923 169 Water Corp: 131375 Local Manager: 0417 182 405 Derby Shire Director of Engineering Services: A/H Emergency: 0418 922 415

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7.6.1 Sewerage Schedule Problem Impact Contingency Action/Task Start date End date Responsibility Sewerage service Unable to dispose

of waste products Alternate toilet

facilities Identify alternate

toilet facilities / devices i.e. portaloos from Wreck Air Hire.

Annual Agreement

Normal service Business Manager Maintenance

Manager

Identify amount of alternate facilities / devices needed and priority use areas

When resources fail

Business Manager Maintenance

Manager

Source supply / cost of alternate devices

Annually Business Manager

Develop protocols for patient use of alternate facilities

Updated annually Director of Nursing

Initiate use of alternate facilities / devices

Loss of all facilities

Normal service Emergency Co-ordinator

Director of Nursing Staff education Educate staff on

contingency plans Orientation Orientation Staff Development

Officer Failure of

contingency Close hospital Transfer patients

out, close hospital Loss of all

facilities Normal service Emergency Co-

ordinator

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7.7 Vehicles and Transport Description: Loss or failure of motor vehicles, Impact Rating: Medium Consequences of resource failure: • Comunnity Health Staff, District Manager and others not able to provide out-reach services Contingency strategy options: Source alternative vehicles (ie. contractors) How long can operations continue in contingency mode: Indefinite Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Fuel shortage Mechanical breakdown/failure Theft of vehicles Damage Responsibility for implementing this strategy: Operations Manager Business Manager Director of Nursing Criteria for returning to normal operating mode: Resource loss issues resolved Vehicles repaired, replaced Can this strategy be tested if so how: No Locations/Providers: BP Colac Service Station: 0409 302 175 / 0400 218 835 Kimberley Car Hire: 9191 1222 / 0447 911 222 Hertz at Broome International Airport: 9192 1428

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7.7.1 Vehicles and Transport Schedule

Problem Impact Contingency Action/Task Start date End date Responsibility Vehicles / Transport loss Field staff unable

to provide out-reach services.

Provide services to communities who need ongoing services

Identify vehicles needed for transport

Continuous Return to normal service

Business Manager

Identify who needs ongoing services

When transport compromised


Business Manager

Initiate use of alternate vehicles

Loss of vehicles Normal service Business Manager



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7.8 Water Supply Description: Loss of scheme water supply to all facilities Failure of hospital bore Impact Rating: Extreme Consequences of resource failure: Cannot provide health service Contingency strategy options: Hospital has 1 bore pump on site – Maintenance Manager has the capacity to hook into the

hospital system via a reticulation system Relocate patients to an unaffected site Contact local supplier- to bring in bottled water. Distribute bottled drinking water – 200 litres kept in Plant Room; distribute to departments. Buy bulk water in tanker from contractors – McCorry Brown see below. How long can operations continue in contingency mode: 20,000 L tank = 48 hours for washing, flushing only (Not for drinking) If bore fails, 1 day's supply only for washing and flushing Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Failure of water supply Responsibility for implementing this strategy: Operations Manager Director of Nursing Business Manager Maintenance Manager Criteria for returning to normal operating mode: Rectification of water supply – supply back to normal Can this strategy be tested if so how: Yes – storage facilities can be tested to see how long they will last. Locations/Providers: Emergency water bore pump on hospital site Water Corporation. Phone: 13 13 75 Local Manager: 0417 182 405 BEP Derby: 9191 1138

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7.8.1 Water Supply Schedule Problem Impact Contingency Action/Task Start date End date Responsibility Loss of scheme Water supply Loss of water

supply for general use

Can use reticulation water for washing flushing, and staff hygiene

Use bottled water for drinking, food preparation

Use bore pump to pump water to reticulation tank

Loss of supply Return to normal supply

Business Manager Maintenance

Manager

Source / cost alternate supplies – bottled water

Annually Completed Business Manager

Loss of drinking water for patients / food preparation

Use bottled water supply

Distribute bottled water supply

Loss of supply Service resumed

Business Manager

Contingency Failure

Close hospital Transfer patients out and close hospital

Total loss of supply

Normal supply Emergency Co-ordinator



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7.9 Steam Failure Description: Failure of both steam generators resulting in an inability to operate sterilisers Impact Rating: Very High Consequences of resource failure: Cannot sterilise surgical equipment, materials for sterilising packs Contingency strategy options: Use Broome sterilizing facilities Purchase pre-sterilised instruments Maintain an increased stock level of sterilised instruments Use chemical sterilisation; materials in CSSD How long can operations continue in contingency mode: Using Broome’s services, indefinite Without contingency, cannot continue in operating theatres Without contingency, prioritise health services, reduce load in A&E Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Failure of steam supply Responsibility for implementing this strategy: Operations Manager Director of Nursing Business Manager Maintenance Manager Theatre Manager Criteria for returning to normal operating mode: Rectification of steam supply – supply back to normal Can this strategy be tested if so how: Yes – turn off steam. Locations/Providers: Emergency water bore pump on hospital site Water Corporation. Phone: 13 13 75 Local Manager: 0417 182 405 Athertons 9249 6166

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7.9.1 Steam Failure

Problem Impact Contingency Action/Tasks Start date End date Responsibility Steam failure Unable to provide

sterilising services Use Broome

sterilizing facilities Make

arrangement with Broome Hospital

On failure of steam supply

Resumption of steam supply

Theatre manager

Purchase pre-sterilised instruments

Locate a supplier of presterilised theatre instruments



Theatre Manager Business

Manager

Maintain an increased stock level of sterilised instruments

Increase stocked levels of sterilised instruments

Ongoing Ongoing Theatre Manager Business

Manager Stores Manager

Use chemical sterilisation; materials in CSSD



Theatre Manager

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7.10 Computer Server Failure Description: Failure of network / servers Impact Rating: Very High/Extreme Consequences of resource failure: No computer network available No access to electronic medical records Unable to order from Central Supply Unable to process financial accounts Unable to create or authorise rosters Unable to process pay Building Management system unable to monitor building services – doors, alarms, air

conditioning, Unable to use communication systems: email Unable to access stored documents on servers: Shared, Nursing, P: drive, other departmental

records held on server. Unable to generate work orders Printers: no access to network printers Contingency strategy options: Switch failure: Use Regional office – ring Kimberley Health Region IT Manager Use modem dial in access from Operations Manager If contingencies above fail: Communications: use phone, fax or in person Medical Records: use hard copies Supply orders: fax or phone, and manual purchase orders Financial accounts: unable to be processed Rosters and Pay: Use dial in system or fax hard copy to Health Corporate Network Building Management system: Use ROAMIO system (palm held unit) Stored documents: Unable to access Work orders: use hard copies Save to disc and print on local printers How long can operations continue in contingency mode: Clinical services: indefinitely Supply services: indefinitely Financial services: hard copy to Perth; use dial in system Rosters & Pay: indefinite Building Management: see Air-conditioning failure. Doors: Alarms: Stored documents: Unable to function

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Work orders: indefinitely Printing: Indefinitely Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Failure of network servers Responsibility for implementing this strategy: Operations Manager Business Manager Maintenance Manager Kimberley Health Region IT Manager Criteria for returning to normal operating mode: Rectification of server loss – supply back to normal Can this strategy be tested if so how: Yes – power down servers. Locations/Providers: Kimberley Health Region IT manager: Steve Vigh 9194 1605 Mobile 0419 912 301 Derby IT: Mathew George 9193 3279 Mobile 0427 931 446

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7.10.1 Computer Server Failure Problem Impact Contingency Action/Tasks Start date End date Responsibility Computer server failure

No computer network available

Use Kimberley Health Region switch

Contact Kimberley Health Region IT manager

Loss of server Restoration of server

Operations Manager

Business manager

No access to electronic medical records

Use paper copies Notify no use of electronic copies

Update electronic copies when server becomes available

Record patient details manually

Enter data when system fixed

Access patient ward lists


Health Information Officer

Central Supply unable to purchase

Phone or fax manual purchase orders

Distribute manual purchase orders


Stores Officer

Unable to process financial accounts

Use dial up modem

Fax invoices to an operating network


Business manager

Regional Supply Officer

Unable to create or authorise rosters

Use dial up modem

Fax hard copy to HCN

Departmental managers to inform staff of consequences


Business Manager

All departmental managers

Continued…

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Problem Impact Contingency Action/Tasks Start date End date Responsibility Building

Management system unable to monitor building services – doors, alarms, air conditioning

Use ROAMIO Connect ROAMIO module where required (maintenance personnel)


Maintenance Manager

Unable to use communication systems: email

Phone, fax, in person

Consider need for communication


All staff

Unable to access stored documents on servers: Shared, Nursing, P: drive, other departmental records held on server.

Unable to use Revert to hard copies of documents

Update electronic versions when server is restored


All staff

Unable to generate work orders

Manual work orders

Distribute manual work orders


Maintenance Secretary

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7.11 PABX failure Description: Failure of PABX Impact Rating: Extreme Consequences of resource failure: No phone communications throughout hospital No phone communication from hospital to outside Contingency strategy options: 4 phones not on PABX:

General Ward 9191 2191 Emergency Dept 9193 1601 Reception 9191 1517 Maintenance 9191 2972

If contingencies above fail: Use mobile phones Use satellite phones Use 2-way radios How long can operations continue in contingency mode: Indefinitely Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Loss of PABX Responsibility for implementing this strategy: Operations Manager Business Manager Maintenance Manager Kimberley Health Region IT Manager Criteria for returning to normal operating mode: Rectification of PABX – supply back to normal Can this strategy be tested if so how: Yes –disconnect. Locations/Providers: Kimberley Health Region IT manager: Steve Vigh 9194 1605 Mobile 0419 912 301 Derby IT: Mathew George 9193 3279 Mobile 0427 931 446 WACHS Communications Manager: 9222 6492 Mobile 0416 924 605 Norwescom: 91921234 Telstra Business Faults and Technical Support: 132 999 NEC: 131 632

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7.11.1 PABX Failure Problem Impact Contingency Action/Tasks Start date End date Responsibility PABX failure No internal or

external telephone communications

4 phones not on PABX: one in General Ward, Reception, emergency department and maintenance

Divert main incoming line to Reception Power Fail Phone

Loss of PABX Restoration of PABX

Business Manager

Telstra Supervisor

Clerical Services

Use email communications for correspondence between departments / organisations

Advise of use of email


Operations Manager

If contingencies above fail:

Use mobile phone communications

Determine essential personel / areas that require a mobile phone during the emergency


Director of Nursing

Business Manager

Call in all non-essential mobile phones for distribution to essential areas


Business Manager

Director of Nursing

Continued…

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Problem Impact Contingency Action/Tasks Start date End date Responsibility Use satellite

phone communications

Determine placement of satellite phones during an emergency


Business Manager Director of Nursing

Collect & distribute Hospital satellite phones



Use 2-way radio communications

Determine placement of 2-way radios during an emergency



Liaise with Police to ensure radio link remains open during an emergency



Collect & distribute Hospital 2-way radios



Maintenance Manager

Broadcast emergency telephone numbers through the media e.g. radio, television

Contact WACHS Communications Manager


Operations Manager

Use a messenger service system within the health service

Develop protocol detailing an emergency messenger service

Operations Manager

Apoint Messenger Business Manager

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7.12 Fire System Failure Description: Failure of Fire system: detection and warning Impact Rating: Low (day to day functioning is not impacted Safety considerations are of high importance Consequences of resource failure: No automatic detection or warning of fire No Public Address system No Warden Intercommunication Phones Contingency strategy options: Increase vigilance – increase frequency of security rounds by orderly Contact repairers and suppliers Inform Fire Brigade How long can operations continue in contingency mode: Indefinitely Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Loss of fire detection and warning systems Responsibility for implementing this strategy: Operations Manager Business Manager Maintenance Manager Criteria for returning to normal operating mode: Rectification of Fire detection and warning systems- back to normal Can this strategy be tested if so how: Yes – disconnect. Locations/Providers: Fire Brigade 000 Wormald Fire Karratha: 9143 1431

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7.12.1 Fire System Failure

Problem Impact Contingency Action/Tasks Start date End date Responsibility Fire System failure detection system failure Warning system failure

Minimal impact on day-to-day functioning

Increase orderly’s security rounds

Contact suppliers and repairers

Loss of fire system

Restoration of fire system

Maintenace Manager

Inform Fire Brigade

Loss of fire system


Maintenance Manager

Notify all staff of alarm failure and order activiation of contigency plan

Loss of fire system


Maintenance Manager

Fire occurs while alarms not working

Refer to fire and evacuation procedures / task cards

Area warden to order evacuation and contact fire brigade

Loss of fire system


Maintenance Manager

Fire warden to organise communication to remainder of complex

Loss of fire system


Maintenance Manager

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7.13 Building Management System Failure Description: Failure of Building Management system Impact Rating: Medium Consequences of resource failure: Discomfort of clients and staff due to inability to adjust Air con Auto alarms for failure of A/c will not work Doors: still operable with proximity cards and sensors but no monitoring of door alarms and

faults No CCTV Contingency strategy options: Increase vigilance – increase frequency of security rounds by orderly Contact repairers and suppliers How long can operations continue in contingency mode: Indefinitely Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Loss of building management systems Responsibility for implementing this strategy: Operations Manager Business Manager Maintenance Manager Criteria for returning to normal operating mode: Rectification of building management systems- back to normal Can this strategy be tested if so how: Yes – disconnect. Locations/Providers: Schneider Electrical Perth, John Evans: 6241 0400 Mobile: 0438 886 283

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7.13.1 Building Management System Failure

Problem Impact Contingency Action/Tasks Start date End date Responsibility Building Management System Failure

Discomfort of clients and staff due to inability to adjust Air con

Connect ROAMIO

Disconnect automated system; adjust manually

Send Maintenance staff to adjust manually

Building management system failure

Building management system restoration

Maintenance Manager

Auto alarms for failure of A/c will not work

Increase monitoring of A/c systems

Send Maintenance staff



Maintenance manager

Doors: still operable with proximity cards and sensors but no monitoring of door alarms and faults

Increase monitoring of doors

Send Maintenance staff



Maintenance manager

No CCTV Increase monitoring

Send Maintenance staff and orderly



Maintenance manager

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7.14 Loss of Supply Description: Loss of external suppliers Disaster in internal supply Impact Rating: Extreme Consequences of resource failure: Inability to restock low resources leading to inability to provide adequate resources for health

care delivery Contingency strategy options: Increase stock levels held on site Source alternative suppliers Reduce low care, low priority patient load Reduce or cancel operating theatre list and clinics Fly in emergency supplies from Perth Emergency Contact Officer Officer WACHS How long can operations continue in contingency mode: 2 weeks Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Loss of supply Responsibility for implementing this strategy: District Manager Business Manager Maintenance Manager Support Services Manager Supply Officer Director of Nursing Regional Pharmacist Criteria for returning to normal operating mode: Return of supply Can this strategy be tested if so how: Yes – don’t restock for 2 weeks.

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Locations/Providers: Regional Supply Manager: 9194 2804 Mobile 0409 818 369 Broome Health Services: 9194 2222 Local food suppliers – Woolworths Derby 9191 1055

Rusty’s IGA 9191 1210 Sampey Meats 9193 2444 Kimberley Distributors Broome 9192 2201

Cleaning chemical suppliers: Progressive Supplies Derby: 1300 853 995 WACHS Emergency Supply contact officer Derby SES Manager: 0418 900 112 or 9191 1501

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7.14.1 Loss of Supply

Problem Impact Contingency Action/Tasks Start date End date Responsibility Loss of supply (external suppliers fairlure or internal disaster in Supply store)

Inability to restock low resources leading to inability to provide adequate resources for health care delivery

Use Local suppliers:

Make arrangement with local suppliers

Ascertain range of supplies carried by local suppliers

Source local suppliers for all required stores

Annual and ongoing

Return of supply Operations Manager

Business Manager

Maintenance Manager


Supply Officer Director of

Nursing

Reduce low care, low priority patient load

Discharge where possible

Make arrangement with Community Care services

Alert community care services

Transfer to community care services

Annual and ongoing

Return of supply Senior Medical Officer

Director of Nursing

Operations Manager

Reduce or cancel operating theatre list and clinics

Reschedule elective surgeries and clinics

Transfer urgent surgeries to Derby

Notify visiting specialists

Loss of supply Return of supply Senior Medical Officer

Director of Nursing

Operations Manager

Continued…

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Problem Impact Contingency Action/Tasks Start date End date Responsibility Fly in emergency

supplies from Perth Emergency Contact Officer Officer WACHS

Arrange source and delivery of emergency supplies

Notify SES if appropriate

Loss of supply Return of supply Operations Manager

Business Manager

Maintenance Manager


Supply Officer Director of

Nursing

Loss of pharmacy supply

Use local suppliers

Source local suppliers

Make arrangements with local suppliers

Annual and ongoing

Return of supply Regional Pharmacist

Continued resource loss beyond 2 weeks

Reduce patient load

Transfer to alternative care suppliers

2weeks after loss of supply

Return of supply Senior Medical Officer

Director of Nursing

Operations Manager

Make arrangements with alternative care suppliers

Annual and ongoing

Senior Medical Officer

Director of Nursing

Operations Manager

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8. DERBY HEALTH SERVICE – ACUTE INPATIENT SERVICES 8.1 General Ward The standard operating procedures for hospital wide resource failure, e.g. medical gases, air-conditioning and lighting, are to be used in conjunction with the following contingency plans. Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general

Unable to perform duties

Contact Engineering Contact Operations Manager

Await advice from Engineering

Maintenance Manager

BME equipment failure Please be aware Engineering can ONLY carry out MINOR repairs and diagnose faults only

Total Failure Litigation

Engineering will advise of condition and arrange repairs by BME

Arrange transfer from other

sources

Check failed machinery Maintenance Manager

Difficulties in patient observation and care

Contact Nurse Manager and Senior Medical Officer

Prioritise patient care Nurse Manager

Oxygen Wall Supply and Suction Failure

Refer to Section 9.1 General Services

All staff

Pan room hopper – sluice not available

Unable to clean bed pans / urinals adequately

Contact Engineering Maximum numbers of pans

available Use Alternative pan hopper

Engineering and Infection Control to diagnose alternative cleansing methods

Educate staff

Infection Control Nurse

Maintenance Manager

Restrict use of bed pans to “bed rest” clients only

Empty used pans / urinals into toilet

Use disposable bedpans if available

Nursing Staff

Continued…

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Problem Impact Contingency Action/Tasks Start date End date Responsibility Refrigeration Drugs and

medical supplies requiring refrigeration may become unusable

Contact Engineering Ensure fridges are connected

to essential power supply outlets

Identify fridges on essential power supply

Nurse Manager

Contact Engineering to check calibration of thermometers etc.

Thermometers in fridge to monitor temperature

Nursing staff

Inform staff Nurse Manager

Remove all unnecessary items from fridge.

Transfer to alternate fridge if necessary

Nursing Staff

Staffing Increased manual tasks may influence workload

Roster extra staff on duty Estimate staffing numbers required for 24hrs period

Director of Nursing/Nurse Manager

Place staff “on-call” Prepare rosters Nurse Manager

Liaise with agencies for extra staff where required including post event

Director of Nursing

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8.2 Obstetrics / Maternity Ward The standard operating procedures for hospital wide resource failure, e.g. medical gases, air-conditioning and lighting, and for the general wards, are to be used in conjunction with the following contingency plans. Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment


Contact Engineering Await advice from Engineering Repairs or alternative feeds to be

determined

Nurse Manager Maintenance

Manager

Infant resuscitation trolleys do not work

Warming and oxygen not immediately available

Use portable oxygen cylinders and warm blankets

Contact Engineering Adequate supply oxygen cylinders Adequate twinovac suction and

attachments

Nurse Manager Support Services

Manager

Ensure cylinders full Support Services Manager

Fill blanket warmer Nursing Staff Dry babies well and wrap and

dress warmly Nursing Staff

Notify Staff Nurse Manager

Oxygen Wall Supply and Suction failure

Refer to Section 9.1 General Services

All staff

Refrigeration of formula and expressed breat milk (EBM)

EBM and formula may become contaminated

Formula made and used as required

Contact Engineering Ensure Refrigerator connected to

essential power supply

Nurse manager

Use fresh EBM or factory prepared formulas

Educate staff Staff development nurse

Thaw frozen EBM and use as per guidelines

Adequate stocks bottled sterile water and formula (powder and prepared)

Nursing staff

Repack frozen EBM into eskies with ice bricks and tiny tag

Discard any defrosted EBM past use by date

Nursing staff

Discard out of date formula / EBM Nursing staff Consent from mothers of use of

formulas Nursing staff

Continued…

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Problem Impact Contingency Action/Tasks Start date End date Responsibility Labour ward beds cannot be worked

Positioning for labour more difficult

Do without Organise suitable alternative beds and arrange storage

Nurse Manager

Inform staff Cariotocograph (CTG) does not work

Unable to continuously monitor foetal heart

Use battery-powered ultrsound doppler

Adequate supply battery operated dopplers and pinnard stethoscopes

Nurse Manager

Use pinnard Educate staff Staff Development Nurse

Increase intermittent auscultation

Identification of vulnerable patients Nursing staff

Check and repair failed machinery Maintenance Manager

Arrange replacement from BME Nurse Manager Monitors Failure including cardiac and oximetry

Unable to identify arrhythmias / oxygen saturation

Increased nursing & medical observation with manual machinery

Identify and position compliant monitors

Nursing staff

Intravenous Medication (as required)

Identify and ensure adequate medical and nursing staff coverage

Nurse Manager

Cardiac massage (as required)

Identification and Prioritisation of vulnerable patients for monitoring

Nursing Staff

Check and repair failed machinery Maintenance Manager

Ensure enough manual equipment Nurse Manager

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8.3 Special Care Nursery

The standard operating procedures for hospital wide resource failure, e.g. medical gases, air-conditioning and lighting, and for the general wards, are to be used in conjunction with the following contingency plans.

Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment


Contact Engineering Await advice from Engineering Repairs or alternative feeds to be

determined

Nurse Manager

Humidcrib Failure Difficulty in regulating neonate’s environment

Contact Engineering Use warm blankets Use infant warmer

Develop unit policy Nurse manager

Dress the infant in warm clothes including bonnet and wrap well using warm blankets

Identify supply of warm blankets Nursing staff

Increase observations to 1/24 temperatures

Educate staff Staff Dev. Nurse

Check and repair failed machinery Maintenance Manager Monitors Failure including cardiac and oximetry

Unable to identify arrhythmias / oxygen saturation

Increased nursing and medical observation using stethoscopes

Use apnoea monitor

Idenify and position compliant monitors Nurse Manager

Intravenous medication (as required)


Nurse Manager

Cardiac massage (as required) Prioritise patients for monitoring and if necessary transfer

Nursing Staff

Replace monitor with other equipment from General Ward/RFDS/Broome Hospital

Investigate close observation of vulnerable patients

Nursing staff

Contact engineering Check and repair failed machinery Maintenance Manager Organise loan equipment from

BME/Broome Hospital Nurse Manager

Suction and Oxygen failure Refer to Section 9.1 General Services

All staff

Phototherapy Equipment Failure

Unable to treat jaundice in infants

Nurse in sunny room but not direct sunlight

Borrow equipment from Broome Transfer to another facility

Nursing staff

Intravenous Pump failure Unable to hydrate neonate safely

Replace with other equipment MO review for change to NGT or transfer to another facility

Nurse Manager

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8.4 Emergency Department The standard operating procedures for hospital wide resource failure, e.g. medical gases, air-conditioning and lighting, and for the general wards, are to be used in conjunction with the following contingency plans. Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment


Await back up generator to start

Contact Engineering

Await advice from Engineering Identify essential power supply

sockets Utilise manually operated

equipment

Nurse Manager

Monitor Failure including cardiac and oximetry

Unable to identify arrhythmia / oxygen saturation

Increased nursing & medical observation

Identify and position compliant monitors

Nurse manager and staff

Utilise battery powered defibrillators/ BP machines/O2 Sats Monitor


Nurse Manager

Prioritise patients for monitoring Nursing staff

Increase observations of vulnerable patients

Nursing staff

Defibrillator does not function Unable to defibrillate patients

Increased nursing & medical observation

Identify and position compliant defibrillator

Nurse Manager

Utilise battery back-up defibrillator

Inform and Educate staff Staff Development Nurse

Ensure batteries are charged on a regular basis

Nurse Manager

Communication Failure Refer to PABX section All staff

Ambulance Breakdown Unable to respond to ambulance calls

Source and use alternate vehicles

Contact ambulance suppliers Notify Operations Manager

Nurse Manager Support Service

Manager

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8.5 Operating Theatre / CSSD The standard operating procedures for hospital wide resource failure, e.g. medical gases, air-conditioning and lighting, and for the general wards, are to be used in conjunction with the following contingency plans. Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment


Conact Engineering Await advice from Engineering

Theatre Coordinator

Anaesthetic machines and ventilators failure

Inaccurate delivery of anaesthetic gases

Hand ventilate Contact Engineering: Application specialist GE Health Care (contact advice on anaesthetic machine)

Theatre Coordinator

Unable to ventilate patients

Use backup cylinder suppiers of O2, nitrous and air

Ensure adequate supply of hand operated ventilation equipment – balck bag, bag – valve device and appropriate cylinders

Theatre Coordinator Support Services

Manager

Utilise oxylogs from Emergency Department (1x Adult 3000; 1x Paeds 2000; 1x Babylog 1000 neonates)

Ensure supplies of cylinder gases Support Services

Manager

Provide air / O2 driven ventilator (oxylog/ birds)

Nurse Manager

Educate staff Staff Development Nurse

Contact Engineering Nurse Manager Monitor Failure including cardiac and oximetry

Unable to identify arrhythmia / oxygen saturation

Increased nursing and medical observation

Theatre Coordinator and Anaesthetist

Utilise portable O2 sats monitor from Theatre (PAC monitor). Other units available in ward or ED


Nurse Manager

Refer to Emergency department contingency plan

Prioritise patients for monitoring Nursing staff

Increase observation of vulnerable patients

Nursing staff

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8.6 Community Health The standard operating procedures for hospital wide resource failure, e.g. medical gases, air-conditioning and lighting, and for the general wards, are to be used in conjunction with the following contingency plans. Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment

Unable to perform duties although some limited clinical work may be able to be performed

Contact Engineering Delay any non-essential

clinical work If hospital is not affected refer

essential clinical work to hospital or arrange clinical space to do clinical work.

Await advice from Engineering If unable to transfer clinical work to

the hospital notify management and prioritise workload

Inform public of issues – if all communications down place notice on town notice boards

Contact hospital maintenance by driving to the hospital if safe to do so

Inform IT so information can be sent out to inform KPHU management and stakeholders of communication and service issues

Discuss essential patient care with DON and SMO at hospital to link in with their contingencies

Maintenance Manager

Community Health Manager

Vaccine cold chain breakdown

See contingency for failure of vaccine refrigerator

See action/ tasks for failure of vaccine refrigerator


Oxygen Supply Home oxygen users may run out of supply and be unable to resupply

Pre-order extra supplies Hospitalisation

Liaise with HACC to identify vulnerable patients


Assess amount of oxygen required and ensure extra supply available


Develop alternative treatment plans including hospitalisation if supply runs out and condition deteriorates


Continued…

of 72


Problem Impact Contingency Action/Tasks Responsibility Reduced ability to

respond effectively to accident, walk in or other emergency situation

Always keep a spare cylinder for each size cylinder in use

Contact hospital for back up if supply urgently required

Organise replacement as soon a cylinder is empty

Check equipment regularly Refer to hospital


Community Health Vaccine Refrigerators

Break in Cold Chain spoils vaccines

Move vaccines to hospital pharmacy using eskie and ice bricks and tiny tags to maintain cold chain

Advise KPHU Infectious Disease Nurse

Advise Engineer


Vaccines can be kept in esky with temp monitor for vaccine clinic and returned to hospital refrigerator at the end of clinic

Inform Regional Immunisation Coordinator (RIC) at Kimberley Population Health Unit (KPHU) and determine the future use or discarding of vaccines (complete wastage report and send to RIC if vaccines discarded)


Record all vaccines being discarded vaccines to Regional Pharmacy

Community health staff

Send all discarded vaccines to Regional Pharmacy


Down load the tiny tag monitor from the Community Health refrigerator


Continued…

of 72


Problem Impact Contingency Action/Tasks Responsibility Computer – HACRe Failure Unable to double

check vaccination status of clients for immunisation

Maintain card system for vaccinations given by Derby Community Health staff

Identify any site with KHR Community Health HACRe


Check parents record Contact AICR with client medicare number


Check vaccination history by phone with AICR (Australian Childhood Immunisation Register)

Located in vaccination book Community health staff

If failure is only local phone

RIC to access record on HCARe

If failure regional consider cancelling clinics

Contact IT for instruction on when services can be restored

Contact RIC to organise to contact as required

Inform public if clinic is to be cancelled

Community health manager

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9. HEALTH SERVICE CRITICAL SERVICES - SUPPORT 9.1 General Services The following standard operating procedures have been generated for application across a number of general services where generic equipment is in place and are grouped thus to avoid replication for tasks for contigency planning for individual services Problem Impact Contingency Action/Tasks Responsibility Oxygen Wall Supply failure Wall oxygen not

available Refer to Medical Gases Section

Wall suction not available

Use cylinder with Twin-o-vac attachment

Contact Engineering Engineering to diagnose and

rectify fault Adequate supply of full air/oxygen

cylinder available

Maintenance manager

Adequate supply of twin-o-vac attachments available

Support services manager

Nurse Manager Identify where equipment is to be

placed (No. requirement) Nurse Manager Nursing staff

Lighting Failure Low light levels may result in OSH issues

Use backup generator Check generator in working order with suuficent fuel in storage

Maintenance Manager

Use areas near to windows Use torches

Clean and maintain windows and fittings


Difficulty in client observation and care

Redepoly / evacuate – clients. Refer to hospital internal disaster plan for evacuation proceedures

Adequate supply of torches / battery operated lights and batteries

Maintenance Manager

Check emergency lighting Maintenance Manager

Clear areas and corridors of hazards

Departmental Managers

Educate staff in evacuation plan & OSH

Staff Development Nurse

Continued…

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Problem Impact Contingency Action/Tasks Responsibility Refrigeration Drugs and medical

supplies requiring refrigeration may become unusable

Ensure fridges are connected to essential power supply outlets

Contact Engineering Maintenance Manager

Ward Managers

Thermometers in fridges to monitor temperature

Ward Manager

Remove all items from fridge Ward Manager Infrom staff Ward Manager Staffing Increased manual

tasks may influence workload

Roster extra staff on duty Estimate staffing numbers required for 24hr period

All Managers

Place staff “on-call” Prepare rosters All Managers Liaise with agencies for extra staff

where required including post event

All Managers

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9.2 Central Sterilisation (Refer also to Section 7.9- Steam Failure) Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment


Contact Engineering Await advice from Engineering

Theatre Coordinator Maintenance

Manager

Steriliser Pre Vacuums fail Unable to process ward and theatre instruments

Alternative sterilisation methods

Contact Engineering Obtain supplies from Broome

Hospital Transport equipment to Broome

for sterilisation

Engineering CSSD Technician /

Infection Control Nurse

Repair failed equipment Manager Engineering / Maintenance/ Atherton Technician

Instrument Dishwasher fails Unable to clean / sterilise instruments

Clean and wash instruments by hand

Manual cleaning of instruments CSSD Technician

Use ultrasonic to clean instruments

CSSD Technician

Ensure adequate supplies CSSD Technician

Educate staff CSSD Technician

Heat Sealer fails Unable to seal instruments pouches

Use alternative sealing methods

Wrap instruments for sterilisation CSSD Technician

hand dry instruments CSSD Technician

Hot air dryer fails Unable to dry instruments

Dry instruments manually Utilise other methods of heat drying eg air compressor

CSSD Technician

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9.3 Medical Records NOTE: The standard operating procedures for the general services are to be used in conjunction with the specific procedures detailed below. Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office equipment

Unable to perform duties Contact Engineering Await advice from Engineering Use manual procedures

Maintenance Manager

Failure of HCare Cannot allocate new MRNs

Manual allocation of MRNs Update manual PMI Medical Records Clerk/Receptionist

Cannot search for existing MRNs

Use folder of printable PMI (Patient Master Index) to look up existing MRNs

Print out PMI quarterly Medical Records Clerk

Contact IT in Perth Manually allocate and look up mRNs

Medical Records Clerk/Receptionist

Update system Medical Records

Clerk/Receptionist

Failure of Admission, Transfer, Separation (ATS)

Cannot search ATS to track patients

Not critical, wait until system returns

Update system Medical Records Clerk

Cannot run enquiry reports

Admission lists available in the ED

Maintain Lists of admissions and discharges

ED Receptionist/ Ward Clerks

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9.4 Pathology Services Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment

Unable to preform duties Contact Engineering Await advice from Engineering Repair or alternative feeds to be

determined

Maintenance Manager

Power Supply Failure Laboratory unable to function without emergency power

Use essential power outlets serviced by emergency generator

Confirm availablity of emergency power

Scientist In Charge

Hand Washing Use bottled water Use Hand sanitiser

Determine suitable hand washing solution

Scientist In Charge

Use prepacked hand washing solution

Adequate supplies hand cleaning solutions

Scientist In Charge

Temperature monitoring software fails.

Unable to determine accurate temperature of Blood Stock fridge & Reagent Fridge

Manual monitoring of fridge temperature using portable probe

Install portable probe Scientist In Charge

Frequent temperature checks Scientist In Charge Alarm monitor failure – Blood Bank Fridge

Rising temperature in fridge may not be recognised. May result in loss of blood supplies, as blood products must be kept at predetermined temperature levels

Monitor fridge temperature manually by portable probe monitor

Pack blood as per blood transport protocols which gives 24hr stability

Install portable probe Scientist In Charge

Transfer blood stores to immunisation fridge

Frequent temperature checks Scientist In Charge

Investigate alternative storage solutions

Scientist In Charge

IT Failure Unable to obtain results Phone 13 7284 for results Photocopy machine printouts

for A+E patients

Nursing and Medical staff

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9.5 Radiology Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment

Unable to perform duties Contact Maitenance Contact IT and BME


Maintenance Manager

Failure of radiological imaging equipment

Unable to perform radiological imaging

Have mobile imaging eqipment available for use

Use mobile imagers Medical Imaging Technologist

Cancel / reschedule non urgent exanminations

Medical Imaging Technologist

Repair failed equipment Engineering Power Failure Main equipment not able

to be used. Situation for failure of equipment

Use essential power outlets for mobile equipment

Identify suitable essential power outlets for use

Engineering

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9.6 Purchasing

Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and general operational equipment

Unable to perform duties Contact Engineering Contact IT


Maintenance Manager

Engineering Information

Technology Supply computer system failure

Unable to generate orders. Unable to access re-order codes and contracts

Revert to manual system. Use manual order book

Adequate supplies manual order books

Manager Stores

Develop a system to allow access to re-order codes and contracts as at time of loss of service

Manager Stores

Inform Staff Manager Stores Retropective data entry system

when system “online” Manager Stores

Unable to access supplier contact details (phone, fax address details)

Refer to Supplier Catalogues Update suppier Catalogues Manager Stores

Print out a report of all supplier names, addresses and contact details as a manual reference

Manager Stores

Connect essential equipment to emergency power outlets

Determine number essential power outlets in the department

Manager Stores

Unable to verify reciept of goods for accounting purposes

Unable to pay suppliers Manual checking of goods and/or verifying with appropiate department

Develop system for manual checking receipt of goods

Manager Stores

Educate staff Manager Stores Unable to extract item and

customer usage reports No feasible contingency

Unable to determine outstanding orders

Refer to full purchasing listing Update purchase listing report Manager Stores

Refer to store copies of orders

Print out a full purchase listing report as a manual reference

Manager Stores

Unable to recharge fork lift Recharge through essential power supply

Locate suitable essential power supply outlet

Manager Stores

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9.7 Linen Services Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment

Unable to perform duties Contact Engineering Await advice from Engineering

Maintenance Manager

Failure of washing machines (2 machines)

Reduced linen service Alter work practices so that other service is maintained

Contact engineering for remedial works

Lengthen washing times


Loss of 3 machines Laundry hours extended to accommodate extra work

Implement contingency staff roster for this situation


Loss of all machines No laundry service Send linen to alternative services – will be external e.g. Broome Hospital

Source alternative linen services e.g. Detention Centre


Arrange transport of soiled and clean linen


Arrange realocation of staff Support Services Manager

Failure of drying machines Reduced drying services Contact engineering for remedial works

Identify area for drying linen Contact Boab Inn to utilise facilities


Chemical Dispenser Failure Linen not washed to correct standard

Contact Maintenance Send linen to Broome for

laundering

Await advice from Maintenance Contact Broome Hospital Support

Service Manager

Maintenance Manager


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9.8 Catering Services Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipement

Unable to perform duties Contact engineering Await advice from engineering Repairs or alternative feeds to be

determined

Maintenance Manager

Ovens fail, no hot food Supply hot food from alternative premesis

Identify other premises for use in preparing hot food e.g. NNNH

Commercial kitchen contractors Hotels etc


Business Manager

Supply cold food Determine supply levels of cold food required


Determine sources to replenish stocks of cold food if system is inactive for a long period


Business Manager Refrigeration / cool rooms fail Food spoilage Cool rooms connected to

emergency generator Check generator every 4 hours Maintenance

Manager Emergency generator

failure Source food off campus Assess availability of emergency

power through Horizon Power Maintenance

Manager Source alternative facilities Support Services

Manager Develop plan for preparation and

transport of food and relocation of staff


Implement plan Support Services Manager

Dishwashers fail Unable to clean dishes Wash equipment by hand Adequate supply of gloves, equipment Support Services Manager

Increase staffing if equipment fails for more than 24 hours


Stores/Supplies not delivered No food Contact Lead suppliers Purchase locally Support Services Manager

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9.9 Mortuary Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipement

Unable to perform duties Contact Engineering Await advice from engineering

Maintenance Manager

Loss of refrigeration Unable to preserve the deceased

Transport deceased to alternative

Transport to Broome Health Service


In event of essential power failure use portable generator

Monitor every 2 hours Maintenance Manager

Use alternative refrigeration (e.g. refrigerated trucks)

Source alternative facilities Support Services Manager

Business Manager Develop plan for preparation and

transport of deceased and relocation of staff

Business Manager

Educate Staff Staff Development Nurse

Implement plan Business Manager Inadequate number of trays in cool room due to disaster

OSH standards compromised

Stack cadavers on cool room floor

Ensure deceased are tagged correctly

Transport to alternative mortuaries

Contact Broome Health Service Sorce alternative cold rooms Educate staff


Maintenance Manager

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Effective:


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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:

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OUTCOMES: PRINT NAME Signature of person completing report: Date Tier 4 Review and Sign off: Date

Copy to Emergency and Disaster Management Committee

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Appendix 2: SERVICES ON ESSENTIAL POWER 1) Lights and power – powered by emergency generator All Ward offices and patient areas have 50% power points on generator supply. The Cleaner’s store, three general offices and the Birth Suite bathroom do not have generator supply. 50% of all lighting is on Generator supply. All emergency lighting and exit lighting is battery powered and will last for two hours in event of generator failure.

Equipment with battery back-up are:

the Infusion pumps the Dynamaps PCAs Defibrillator Pulse Oximeters.

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Appendix 3: MEDICAL GASES ESSENTIAL SUPPLY Oxygen:

i) 10 x G in Medical Gas Store

ii) 5 x E in Medical Gas Store

iii) 9 x D in Medical Gas Store

iv) 34 x C in Medical Gas Store

v) 2 x C in Theatre Store

vi) 3 x C in Accident and Emergency Store

vii) 8 x C in General Ward Store.

Nitrous oxide:

i) 2 X C in Medical Gas Store

ii) 2 X E in Medical Gas Store

iii) 2 X C in Theatre.

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