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Mackay Hospital and HealthService
Business Continuity Plan
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Table of ContentsIntroduction................................................................................................................... 3Purpose ........................................................................................................................ 3Support / Interface with other plans .............................................................................. 3Geographical Area........................................................................................................ 3Types of Hazards ......................................................................................................... 4Pandemic Influenza ...................................................................................................... 5
Reducing the likelihood of staff becoming exposed to the virus ............................ 5Management of illness and absenteeism .............................................................. 5Maintaining service/business delivery with specific reference to the maintenanceof essential services .............................................................................................. 6Staffing .................................................................................................................. 6Staff accommodation............................................................................................. 6
General Operations ...................................................................................................... 6Communications........................................................................................................... 7Activation and Relocation ............................................................................................. 7Risk Management......................................................................................................... 8Business Restoration.................................................................................................. 11Conclusion.................................................................................................................. 11Contingency Plans For the Mackay Hospital and Health Service ............................... 12
Occupational Health and Safety Unit ...................................................................... 13Medical Ward.......................................................................................................... 15Rehabilitation Unit................................................................................................... 22Operating Theatre Services .................................................................................... 25Intensive Care Unit ................................................................................................. 34Coronary Care Unit ................................................................................................. 37Womens Health Unit ............................................................................................... 40
Special Care Neonatal Intensive Care Nursery ................................................... 42Womens Health Unit – Ward & Clinics ................................................................ 45Birth Centre ......................................................................................................... 50
Child & Adolescent Health Unit............................................................................... 51Specialist Outpatients ............................................................................................. 60Renal Dialysis Unit.................................................................................................. 65Mental Health Unit .................................................................................................. 67Community Mental Health....................................................................................... 70Alcohol Tobacco & Other Drugs Service................................................................. 73Early Discharge Surgery Unit.................................................................................. 75Mackay Breastscreen ............................................................................................. 84CSSD...................................................................................................................... 85Health Information Division ..................................................................................... 87Corporate Services Travel ...................................................................................... 89Information Division ................................................................................................ 90Medical Imaging...................................................................................................... 92Pathology Services. ................................................................................................ 95Pharmacy................................................................................................................ 97Bowen Hospital – General & Clinical Services........................................................ 99
Bowen Hospital – Utilities Services ................................................................... 106Clermont Hospital - General ................................................................................. 110
Clermont Hospital – Utilities Services................................................................ 117
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Monash Lodge – General .................................................................................. 122Monash Lodge – Utilities Services .................................................................... 128
Collinsville Hospital - General ............................................................................... 133Collinsville Hospital – Utilities Services ............................................................. 141
Dysart Hospital – Clinical & General ..................................................................... 146Dysart Hospital – Utilities Services.................................................................... 153
Moranbah Hospital................................................................................................ 157Proserpine Hospital – Clinical & General .............................................................. 162
Proserpine Hospital – Utilities Services ............................................................. 172Sarina Hospital – Clinical & General ..................................................................... 183
Sarina Hospital – Utilities Services.................................................................... 186Environmental Services............................................................................................ 190Catering Services ..................................................................................................... 194Linen Services .......................................................................................................... 196Emergency Call Directory ......................................................................................... 198
Contact List – Internal ........................................................................................... 198Contact List – External.......................................................................................... 198
Operational Checklist ............................................................................................... 199Glossary ................................................................................................................... 200Amendment register and version control .................................................................. 200APPENDIX 1 ............................................................................................................ 201
Terms of Reference - Emergency Preparedness and Continuity Management Sub-Committee ............................................................................................................ 201
APPENDIX 2 ............................................................................................................ 202MODEL HEALTH INCIDENT MANAGEMENT CHECKLISTS.............................. 202
State Health Coordinator ................................................................................... 202Health Incident Controller .................................................................................. 202Site Medical Commander .................................................................................. 203Planning Officer................................................................................................. 203Logistics Officer................................................................................................. 204Liaison Officer ................................................................................................... 204Media and Communication Officer .................................................................... 204
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Introduction
The aim of the Mackay Hospital and Health Service (MHHS) Business Continuity Plan (BCP) is to promotecontinuity and rapid recovery of critical services or functions required to support the core business of the HealthService. It is a continuous improvement process of establishing and maintaining Business Continuity Plans andother measures in order to respond to and recover from disruptions that threaten key resources, locations andfunctions. Major disruptions can arise from both dramatic crises and from the escalation of routine managementand business failures within an organisation, and poor decision making.
In this plan, business continuity is an all embracing term which addresses organisational recovery following adisaster. It assumes that prevention arrangements have failed and that an incident has occurred which hasinterrupted normal business to the extent that corrective action is required. It aims to provide the availability ofprocesses and resources in order to ensure the continued achievement of critical objectives.
Purpose
The plan will outline the arrangement guidelines for Business Continuity within the MHHS in accordance withGovernment Agency Preparedness for Government for Queensland Government Departments. It will detail thekey people, the responses and actions needed to enable the MHHS to continue essential functions in the event ofa disaster.
Individual areas within the MHHS will be required to have a Business Continuity Plan that clearly identifies thefollowing;
Processes carried out within the section Impact of possible events Contingency plan Tasks and allocated responsibilities Approximate time frame they can survive without the service
The Emergency Planning committee (EPC) is responsible for establishing and implementing emergency plans andprocedures that include prevention, preparedness, response and recovery strategies.
The EPC for the MHHS is a sub group of the Safe practice & Environment Committee (SP&E) and is convened asnecessary with members being coopted for an advisory capacity. This committee is responsible for theidentification of internal and external stakeholders obtaining input from local emergency services to ensure acoordinated response.
Support / Interface with other plans
This plan has been developed in accordance with the Qld Health Disaster Plan 2008 and supports / interfaces with: Queensland Health Policy Statement 28028 Emergency Preparedness & Continuity Management,
September 2006 Occupational Health & Safety Management and Emergency Preparedness and Continuity Management:
Implementation Standard 1-28#21 MHHS Emergency Manual, NC-WPI161 - V1.0 July 2009 Standards Australia and New Zealand - HB292:2006 & HB293:2006 Business Continuity Management Standards Australia and New Zealand AS/NZS4360:2004 Risk Management
Geographical Area
This plan has been developed to cover the Mackay Hospital and Health Service which encompasses the followingshires Mackay, Whitsunday and Isaac Region with total population 163,060. Health facilities include:
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The Mackay Hospital and Health Service
Bowen Hospitalo 27 beds
Clermont Multipurpose Centreo 10 bedso 6 aged careMonash Lodgeo 16 Aged Care
Collinsville Hospitalo 8 bedso 7 aged careo Population (2007) 13,370
(Includes Bowen & Collinsville) Dysart Hospital
o 7 beds Mackay Base Hospital
o 162 beds Mackay Community Health Centre Moranbah Hospital
o 12 bedso Population (2012) 12,000
Proserpine Hospital & WhitsundayCommunity Health Centre
o 33 bedso Population (2007) 18,610
Sarina Hospital & Primary Health CareCentre
o 16 bedso Population (2007) 11,440
Population data extracted fromhttp://qheps.health.qld.gov.au/hic/infobank/POPPROJ/proj_lga_medium2006v.xls
Types of Hazards
A disaster, event or hazard will cause stress and extra load for the MHHS health care facilities. Hazards are oftenassociated with injuries and death. The aftermath of a hazard may lead to an increase or a perception that therewill be an increase in disease, placing stress on the MHHS to maintain continuity in health care provision andrecovery.
Far North Queensland's diverse climate conditions give rise to a number of hazards. During the Wet Season,flooding can occur over large areas of the MHHS cutting communication, causing landslides and damaginginfrastructure. Cyclonic conditions from November to April further compound this hazard with the risk of stormsurge.
Hazards and associated risks include:
earthquakes—deaths and injuries, mainly due to building collapse; flooding—drowning and injuries; storms and cyclones—deaths and injuries due to debris impact or building collapse, drowning; fire—deaths and injuries due to burns, smoke-inhalation or respiratory failure in vulnerable people:
explosions—deaths and injuries due to building collapse, burns; chemical spills or leaks may cause a range of injuries from burns to respiratory problems; the perceived risk of epidemics will place significant extra load on health-care facilities; primary health-care services must be maintained while the stress levels associated with an emergency or
disaster may actually increase normal rates of heart attacks, strokes, childbirths (as hyperbaric pressuredecreases during cyclones), psychological effects and availability of medication; eg. Methadone etc.immediately after the event; and
lack of power may increase loads on health systems by:
the general public using naked flames for heating or lighting, with increased fire risk andrespiratory problems;
use of generators with inadequate ventilation may cause suffocation or respiratory problems.Handling generator fuel may cause fire risks;
eating contaminated foods or out-of-date foods may lead to gastric disorders; Injuries to persons trying to navigate flooded areas and lack of power for in-home care of disabled or ill people may lead to these people seeking in-
hospital care.
As well as increased loading on the MHHS, the hazard itself may impact on Queensland Health’s ability to providea health care service. This could be due to the following:
damage to health infrastructure housing the facilities that may make them unsafe for continuing service; water damage (mould), cladding damage or smoke damage that may make the facility unserviceable.
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Equipment may have been damaged, records lost or cleanliness compromised;
Some facilities within the MHHS; such as Community Health and Victoria Street facilities may not haveemergency power or their premises may be inundated or damaged and may be unable to provideservices.
Staff shortages may occur following hazards, as casualties elsewhere in the community, damage totransportation and general community disruption may mean that staff rostered on cannot come to work.
Some equipment may have been affected by the hazard itself. Mobile or portable equipment is vulnerableto damage in cyclones & earthquakes. Equipment that makes use of gas or gases (critical services inparticular) may be compromised by leaks in pipes or damage to reticulation system or lack of supply, andgas storage areas could be compromised.
Many of the above effects have the added complication that the staff and patients of these facilities mayneed to be evacuated, placing extra load on surrounding facilities, and also risking the safety of peoplewho require continuous care or specialised equipment.
Pandemic Influenza
The MHHS must work with other health related agencies to determine how best to assist in responding to thehealth and wellbeing needs of the community during a pandemic, as well as minimising the impact of a pandemicon the service.
In order to reduce the impact of a pandemic on core business and maintain business continuity, absenteeismneeds to be effectively managed. Items to be considered are:
Reducing the likelihood of staff becoming exposed to the virus
Education can reduce fear through understanding and help protect through knowledge. Basic information that staffshould be made aware of includes:
What is pandemic influenza and how is it spread? What are the signs & symptoms? When are people considered infectious? What can be done to reduce the risk?
Note: Under the Workplace Health and Safety Act 1995 the obligations that an organisation has under this Act continue to apply in the event ofpandemic influenza. An organisation must continue to manage everyday risks to the workplace health and safety of workers and others, as well asmanage risks unique to pandemic influenza.
Management of illness and absenteeism
Well developed workplace policies are integral to the protection of the workforce and the organisation’s operationsduring a pandemic. Policies that can be considered include, but are not limited to the following topics:
Hygiene and cleaning practices Social distancing strategies incorporating - working from home, using company vehicles, restricting
access to the workplace, change to working rosters / hours of operation Work related restrictions on travel to affected areas
Maintaining service/business delivery with specific reference to the
maintenance of essential services
A Pandemic may create the need for staff members to remain at home to care for their dependants, and mayreduce the numbers of staff that attend work due to fear of the disease, or as an unwillingness to place themselvesat a risk of infection.
Key tasks to be undertaken are: Identify the core people required to keep the essential functions of the business running Identify opportunities for cross training/multi skilling of staff where appropriate with the intent of creating a
larger internal resource base from which to draw on Identify retired staff that may be employed for knowledge as opposed to physicality Identify critical resources and projected quantities (required to maintain functioning of key areas) over the
peak period of the pandemic. This can be used to assess the feasibility of bulk purchases/stockpiling Discuss preparedness planning with key suppliers/contractors. Identify all suppliers of the required resources beyond current contractual arrangements.
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Identify temporary alternatives and suppliers Identify the Critical Breaking Point.
Staffing
The effects of a pandemic on staffing numbers can only be estimated before the actual occurrence. It is notunreasonable to assume that at various times during a Pandemic the MHHS will experience significant levels ofabsenteeism whether directly related to influenza infection, family care responsibilities or fear and fatigue. This maybe as high as 30 - 40% absenteeism at the height of an outbreak.
It is important to note that an influenza pandemic will not be ‘business as usual’ for health services in Australia.Staff will be required to work flexibly to meet increased demands; usual clinical and infection control practices mayneed to be altered to accommodate the exceptional circumstances.
Depending on the epidemiology and virulence of the virus the MHHS may have to rationalise certain services inorder to maintain the ability to provide services directly related to a Pandemic Influenza outbreak.
Historically Pandemics have come in waves of between 6-12 weeks; changes to service provision will benecessary but temporary.
Staff should be discouraged from presenting to work with flu like symptoms, especially in the early stages whereprevention of spread will be paramount to the governments’ containment strategies. As the stages of a Pandemicwave progress the staff who have recovered will have immunity and be able to work in the front line of theresponse with little risk of further infection from pandemic influenza.
Staff accommodation
During some stages of a critical incident or pandemic there may be a need for staff accommodation within or closeto the Hospital. The reasons include:
Reduced staff available, increasing the need for overtime and extra shifts Staff wishing to remain at hospital rather than risk transmission to family.
If the Hospital staffing is hit hard then it may be that many staff will be required to work extended hours and extrashifts, all possible measures should be taken to ensure safe practice and to keep fatigue to a minimum.
For more information see: MHHS Pandemic Influenza Plan, C-WPI242 – V2.0 May 2009
General Operations
Strategies that may be required to be utilized(These will vary depending upon the type and severity of the Incident)
Temporary Cessation of all elective admissions and procedures at Mackay Base Hospital Temporary closure of Medical and Surgical Clinics, Deployment of staff to areas of greater need and to cover absenteeism will be common, Some staff will be required to perform their roles in new environments Multiskilling in areas of the same job stream but different roles
All wards and departments within the MHHS should develop an area specific contingency plan that givesconsideration to how they may function in any given incident that may arise. Work requirements should beprioritised.Consideration should be given to:
Patient Flows patients to and from units Succession planning, Mulitskilling where appropriate Changes to work practices that may occur Preparation for “knock-on” effects from other departments that may affect your departments functionality
Some departments within the Mackay Health Service will have to maintain elements of their core business,possibly at a reduced level because their service may not be able to be completely absorbed by other hospitals in
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the MHHS. These may include Emergency Department, Intensive Care Unit, Coronary Care Unit, Theatres,Maternity, Renal, & Mental Health.
Communications
Locally, where an incident threatens to disrupt normal operations, immediate decisions are required to minimise theimpact of the incident and to resolve issues where possible.
In the event of a crisis, the delegated Health Incident Controller will initiate the Emergency Operation Centre tomanage immediate response activities—for example, authorising and releasing communications with staff andstakeholders, authorising the activation of business continuity and information disaster recovery arrangements,standing down staff, declaring the crisis over.
The Emergency Operation Centre would normally include relevant senior and functional managers, or theirdelegates, who can provide leadership and who understand agency operations. Sub-groups can also be identifiedto support the crisis management team.
The State Disaster Management Group meet and manage disaster arrangements. Queensland’s DisasterManagement arrangements are managed by the Department of Emergency Services (seewww.disaster.qld.gov.au).
Activation and Relocation
The MHHS will be activated and deployed in an appropriate authorised manner according to procedures set out inthe MHHS Emergency Manual
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Risk ManagementPossible Types of Exposure and the Risk Assessment:(According to the Queensland Health Risk Management Matrix (Integrated Risk Management ImplementationStandard 3)It is assumed that any major loss of hospital/facility global essential resources (eg. Power, fuel, gases, water,communications etc) will be addressed and co-ordinated through the MHHS Disaster Coordination Centre.
Risk Description Likelihood Consequence Risk RatingEarthquake (deaths & injuries dueto building collapse)
Rare Extreme High 15
Storms & Cyclones Rare Extreme High 15
Flooding (drowning & injuries) Unlikely Major High 14
Fire (deaths & injuries due to burns,smoke inhalation or respiratory failurein vulnerable people)
Rare Major Medium 11
Fire Alarm Failure Rare Extreme High 15
Water Failure Rare Extreme High 15
Electricity Failure (public or staffmay use a naked flame for heating orlighting with an increased fire &respiratory problems)
Possible Moderate High 13
Gas Supply failure Rare Moderate Low 5
Medical Gas Failure Rare Extreme High 15
Damage to Infrastructure(following an event – impact uponability to provide health service)
Rare Extreme High 15
Water Damage making thefacility unserviceable
Unlikely Major High 14
Capacity of the Hospital isexceeded
Likely Major Very High 20
Industrial Disputes Possible Major Very High 19
Epidemic/Pandemic Possible Major Very High 19
Computer system failure –greater than 1 day
Possible Moderate High 13
Bomb or Explosions (deaths &injuries due to building collapse &burns)
Rare Extreme High 15
Chemical Spills & Leaks (rangeof injuries from burns to respiratoryproblems)
Rare Major Medium 11
Biological Incident – escape,spillage or contamination
Rare Major Medium 11
Radiological incident Rare Major Medium 11
Adverse Public interest Possible Major Very High 19
Major engineering failures -burst water mains, electrical sub-station failure, generator failure etc. Impact upon buildings - helicopter or aircraft Chemical spill in vicinity of hospital - road tanker Communication Systems failure
Medical Gas Reticulated Systems failure - oxygen, suction
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Integrated Risk Management Analysis MatrixThe use of integrated Risk Management Analysis Matrix is mandatory when communicating risks (risk Ratings) to Executive andSenior Management throughout the Department.The Integrated Risk Management Analysis Matrix is used to assess Consequence(s) should the risk occur and Likelihood(Probability) of the Risk occurring. Together, the Likelihood and Consequences(s) determines an overall Risk Rating or Level of risk.
CONSEQUENCE TABLE (Consequence Table for types of consequences and degrees of severity)
Degree of SeverityType of Consequence NEGLIGIBLE MINOR MODERATE MAJOR EXTREME
Adverse ClinicalEvent
C No injury or harmcaused, minoradjustment tooperational routine
Minimal harmcaused, minorinterruption toroutine
Loss of function,major harm caused
Permanent loss offunction or disability
A loss of life
Outrage/Damage toReputation
O Minimal adverselocal publicity
Significant adverselocal publicity
Significant adverseStatewide publicity
Significant andsustained Statewideadverse publicity
Sustained nationaladverse publicity,Queensland Health’sreputation significantlydamaged
Litigation L Potential exposure toQueensland Health
Minor exposure toQueensland Health
Exposure will resultin a single claim
Claims greater than$500,000 or multipleclaims resulting fromsingle exposure
Claims greater than$1M or multiple claimsresulting from multiplesimilar exposures
Disruption toEstablishedRoutines/Operational Delivery
D No interruption toservice
Some disruptionmanageable byaltered operationalroutine
Disruption to anumber of areaswithin a location orMHHS, possible flowon to other locations
All operational areas ofa location or MHHScompromised, otherlocations or MHHSs areaffected
Total systemdysfunction and/or totalshutdown of operations
Staff Morale(may includeabsenteeism,establishment)
SM Staff dissatisfactionwithin local unit. Noeffect on services orprograms
Alteration to routinepractice required inlocal area or MHHS
Disruption spreadsacross services orprograms
Disruption spreads toroutine practiceStatewide
Statewide cessation ofservice or programs
Workplace Health &Safety
H No injury/illness – notime lost, minoradjustment tooperational routine
No lost time injuryFirst aid or medicaltreatment required
Lost time injuryinvolving atemporary loss offunction or anotifiable event
Permanent loss offunction or disability
A loss of life
Security(may includefraud/theft.Unauthorised accessand areas ofsuspected officialmisconduct)
S Event noted by localstaff/management,no change to routineoperations
Monitored by localstaff, some effect onroutine operations
A security event thatmay threaten aprogram /service. Anevent requiringinternal investigation
Major event thatthreatens a program/service across thewider organisation.Events requiringreferral to Police / CMC
Extreme event affectinga program / serviceareas ability to continueits operation resulting intotal shutdown
EnvironmentalImpact(may includedischarge ofhazardous ordangeroussubstances, carbonfootprint etc)
E No lastingdetrimental effect onthe environment
Local detrimentaleffect on theenvironment
Short term localdetrimental effectcontained withoutside assistance(i.e.QFRS, EPA)
Long term detrimentaleffect contained withoutside assistance(i.e.QFRS, EPA)
Having a long lastingeffect on theenvironment
Workforce Issues(may includerecruitment andretention, capability
W No effect on servicesor programs
Some effect onspecific service orprogram – alterationsto routine practicerequired
Restrictions toservice/programavailability within alocation or MHHS,with possible flow onto other locations
Cessation ofservice/program of alocation or MHHS,which could impactother locations orMHHSs
Statewide cessation ofa program or multiplrprograms
OperationalManagement
OM No impact on localoperations
Minor impact on localoperations
Moderate to longterm impact on wideroperations
Major impact onoperations across otherareas of organisation
Cessation of someoperations
CorporateManagement
M Local managementreview
Local managementreview on a broaderbasis
Senior Managementreview orintervention
Directorate/MHHS/Health ServiceExecutive Managementreview or intervention
Statewide managementreview or interventionby EMT / D-G
Financial(anything that has afinancial impact
F ~ 1% of monthly /cost centre budget
~ 2% of monthly /cost centre budget
~ 5% of monthly /cost centre budget
~ 10% of monthly / costcentre budget
~ 15% of monthly / costcentre budget
Please note that the severity for each consequence type is to be considered separately and not relative to each other
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Likelihood (probability) Table
This table defines the likelihood or probability of the risk occurring, based on the information available at the time of assessment.
Rare May occur in exceptional circumstances only / May occur at least once in a period of 5 years or moreUnlikely Might occur sometime but not expected / Might occur at least once during a period of five years or lessPossible Could occur, capable of happening, foreseeable / Could occur at least once in 12 monthsLikely Is expected to occur occasionally / Is expected occur at least once per monthAlmost Certain Is expected to occur frequently, in most circumstances / Is expected occur at least once per week
Integrated Risk Management Analysis Matrix
←Consequences→Likelihood ↓ Negligible Minor Moderate Major Extreme
Rare Low (1) Low (4) Low (5) Medium (11) High (15)Unlikely Low (2) Medium (8) Medium (10) High (14) Very High (21)Possible Low (3) Medium (9) High (13) Very High (19) Very High (22)Likely Medium (6) High (12) Very High (17) Very High (20) Extreme (24)Almost Certain Medium (7) Very High (16) Very High (18) Extreme (23) Extreme (25)
LegendLow risk (1-5) Manage by routine procedures, unlikely to need specific application of resources
Medium Risk (6-11) Manage by specific monitoring or response procedures locally
High Risk (12-15) Management attention needed and management responsibility specified to controlthe risk
Very high risk (16-22) Detailed research and management planning required at a senior management /executive level
Extreme risk (23-25) Immediate action and involvement required at a senior management /executive levelto control the risk
Actions required in response to the level of risk:
Risks with a residual risk rating of Very High (16-22) and Extreme (23-25) must be reported.The management must consider the need for legal advice or guidance. If legal advice or guidance is required itmust be reported to Corporate Counsel (or delegate)All notifiable events (as per the local policy or procedure) must be reported as directed.All incidents including near misses must be reported.The risk assessment process is applicable to all processes and levels within the Department.
SourceIntegrated Risk Management Implementation standard 3 – Risk Analysis Matrix:htpp://qheps.health.qld.gov.au/audit/RM_Stream/RM_Policy/31237_ 08_ 2.0.pdf
(September 08)
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Business Restoration
Following the activation of business recovery arrangements to re-establish all core services, arrangements will beinitiated to restore normal operations to pre-crisis capacity.
The extent and duration of business restoration planning will depend on the impact and nature of the crisis.Business restoration might require, for example, sourcing new accommodation and equipment, re-establishing non-core or strategic processes or projects, transitioning temporary service delivery arrangements established underbusiness recovery to a permanent status or relocating staff and resources to new permanent accommodation.
Pre-planning for business restoration is difficult due to its circumstantial nature and the inherent number ofunknowns.
In the event of a major incident, Queensland’s disaster management arrangements would be activated tocoordinate recovery activities across the affected area and this may impact on the Mackay Health Service businessrestoration planning.
Conclusion
Business continuity arrangements are the MHHS’s last line of defence in risk management arrangements. Theyaddress the immediate crisis, re-establishment of the delivery of core services and essential business operations,and the restoration of the facilities to normal operations following a major interruption.
Business continuity thinking will commence as soon as an abnormal incident occurs even if not considered a majorincident, as this could herald the impending need to activate business continuity arrangements.
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Contingency Plans For the Mackay Hospital and Health Service
1. Contingency Plans for the Mackay Hospital and Health Service
Air Conditioning Failure Boilers Building Management System Gas Supply Human Resource management Mains Electrical Power (See Emergency Manual) Medical Gases, Air and Suction Occupational Health & Safety services Safety and Security Sewerage Telecommunications (See Emergency Manual) Vehicles and Transport (including fuel supply) Water Supply
2. Contingency Plans for Hospital Clinical Services General Surgical Unit/Medical Ward/Rehabilitation Ward Emergency Department Operating Theatre Intensive Care Unit Coronary Care Unit Womens Health Unit
Special Care/Neonatal Care Nursery Ward & Clinic Birth Centre
Child & Adolescent Unit Renal Dialysis Unit Specialist Outpatients Mental Health Community Mental Health
Alcohol & Other Drug Service Early Discharge Day Surgery Unit
3. Contingency Plans for Hospital Support Services
Breastscreen Catering Central Sterile Supply Department Cleaning Health Information Records Information Department Linen Medical Imaging Mortuary Pharmacy Pathology Stores/Supples
4. Contingency Plans for Rural facilities
Bowen Hospital General & Clinical Bowen Utilities Clermont hospital Collinsville Hospital General & Clinical Collinsville Utilities Dysart Hospital Moranbah Hospital Proserpine Hospital Sarina Hospital General & Clinical Sarina Utilities
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Business Continuity Planning
Occupational Health and Safety Unit
The Unit has ten (10) staff, including AO5 OHS Unit Manager (Hinterland) and is based at 73 Victoria Street, Mackay.Note: The Action Cards, Pandemic Influenza Plan 2009, for corporate services and all Managers are to be used in conjunction with the specific procedures detailed below.Key contact: Wendy Macfarlane, MHHS OHS ManagerDelegated as necessary in the following order: Gail Cameron, Susie Maddox, Wayne Vidler
OCCUPATIONAL HEALTH AND SAFETY UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you function without this
service?
Insufficientstaff
Unable to provide promptor timely response for riskassessment, advice,records management orW/Comp casemanagement
Prioritize to addresshighest risk/s first
Undertake Executive Membersdirections / negotiatealternatives
MHHS OHS Mgr Indefinitely, but with a limited service
Identify tasks to be postponeduntil disaster subsides; cancelall unnecessary commitmentsaway from baseAssign tasks to existing staff,monitor progress / wellbeingthroughout dayDetermine staff availability ifshifts needed in addition to8:00-17:00 Mon-Fri.Availability may change daily.
Engage admin supportfrom MHHS units
An unlikely option - other units will be experiencing insufficientstaffing also
Engage expertise fromother Health Servicesand/or corporate
Arrange travel to Mackay ifnecessary
Coordinate scheduled dailybriefing time / place
Confirm primary andsecondary contact detailswhether in Mackay or otherlocation
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OCCUPATIONAL HEALTH AND SAFETY UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you function without this
service?
Staff working from home ifpracticable
Provide laptops and mobilephones / chargers
Determine infection control,task assignment and scheduleam/pm briefing to MgrLiaise with agencies for extracritical care staff
Call staff in when possible
Pool Vehiclesunavailable
Delay in attending toissues needing face-to-face away from Victoria Stcampus; delay transportingill staff to their residences
Use taxi service, ifavailable, or privatevehicles
Identify which staff accept touse their private vehicles
Equip each staff spraydisinfectant and tissues forvehicleEnsure mobile phones arecharged and taken on alltransfers; ensure Mackaystreet maps for all cars
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Business Continuity Planning
Medical & Surgical Wards
The following Standard Operating Procedures have been generated for application across clinical units where common processes exist and are grouped thus to avoid replication oftasks for contingency planning for individual wards.
MEDICAL AND SURGICAL WARDSA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICEComputerfailure
Unable to generate IDLabels
Record patient details manually Ensure supply of HBISCUS downtimeforms
Pre print labels on existing patients Hand write on blank labels for new
admissions
Administrative and nursingstaff
B
B
B
Unable to track patientlocation and bed status
Revert to the manual process Update patient location and bed statusat regular intervals
Notify after hours manager of all patientmovements
Develop a process for disseminatingpatient updates as part of the facilitycommunication plan
Administrative and nursingstaff
Nursing staff
Nursing Staff TeamLeader
B
B
B
Unable to provide patientdietary requirements
Revert to manual process Update patient diet lists and haveavailable for collection by cateringservices
NUM and Team LeaderB
Unable to recordinformation relating topatient nursedependency
Revert to manual process Ensure supply of downtime formsavailable to record information
Administrative StaffB
Unable to accesscomputerisedpathology/radiologyresults
Revert to manual process
Use portable phones if working
Ensure supply of Medical Imaging &pathology result forms
Develop means for notification ofMedical Imaging & laboratory testresults
Manual ordering of tests
Administrative staff
NUM, Medical Imaging &Laboratory Staff
B
B
B
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MEDICAL AND SURGICAL WARDSA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICEEnter data when system is fixed Ensure retrospective data entry when
computer services resume Backup any non centralised data or
ward specific computer programs
Medical & Nursing StaffUnit Manager, MedicalImaging & Laboratory staff
Administrative Staff
B
B
Power Failure Mains power notavailable
Refer to mains power failure plan Inform and Educate staff NUM & Nurse Educator Depends upon thegenerator
LightingFailure
Difficulties in patientobservation & care
Increased risk forpatients and staff
Utilise the emergency lighting
Maximise natural lighting
Utilise alternate lighting
Maintain WH&S precautions
Refer to facility wide power failureplan
Identify provision for emergency lighting Relocate immobile patients to the best
lit areas Ensure there are NO mobile patients
because of increased risk of injury ifthey move about in poorly lit areas
Clean & maintain windows & fittings Ensure blinds & curtains are open Ensure adequate supply of torches &
Battery operated lights & batteries Clear patient areas, work areas &
corridors of all hazards Inform and Educate staff
Engineering staff
Nursing Staff
Nursing Staff
Cleaning Staff
All staff
NUM
NUM & All staff
Educator
B
B
B
B
B
B
B
BAirConditioningFailure
Unable to regulate thetemperature &environment
Use alternate cooling devices egElectrical or manual fan
Refer to facility wide failure plan
Position fans for maximum benefit Identify patients requiring cooling Inform & Educate staff
Nursing Staff
Nursing StaffEducator
Depends upon theweather season in
Mackay
TelephoneFailure
No internal or externaltelephonecommunications
Refer to facility widetelecommunications failure plan
Inform & Educate staff NUMTeam LeaderEducator
A
Wall Oxygensupply failure
Wall oxygen notavailable
Use Oxygen cylinder Identify anticipated requirements ofcylinder oxygen for ward patients
NUMA – B
Page - 17 28/08/2013
MEDICAL AND SURGICAL WARDSA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICE
Provide emergency oxygen/suction
Order required cylinders from centralstorage area
Ensure all oxygen cylinders are full Ensure a corresponding number of
oxygen fittings available at ward level Consider co-locating high oxygen users
(run on the same bi-connectors) Ensure small oxygen cylinder with twin-
o-vac suction on resuscitation trolley Educate staff on use of alternate
devices
NUM
Wards person
Wards person
Nursing & Medical staff
Nursing Staff
NUMEducator
A – B
A – B
A – B
A – B
A – B
A – B
Digital Scalesfail
Unable to record weight Use alternative scales Purchase bathroom scales Use weighted scales if available
NUM
NUM
C
CFailure ofTymphanicThermometer
Potential for inaccuracyof temperature readings
NUM
Failure of non-invasive BloodPressuremonitors
Unable to electronicallymeasure blood pressurereadings
Use manual sphygmomanometer Ensure adequate number ofsphygmomanometers
NUM A
Page - 18 28/08/2013
MEDICAL AND SURGICAL WARDSA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICEFailure ofglucometer
Potential for decreasedaccuracy in bloodglucose readings
Visual readings
Utilise from CNS Stock fromCommunity Health
Formal laboratory blood glucoseanalysis for abnormal results
Ensure adequate stock of batteries Inform & educate staff
Develop policy for formal laboratory test
NUMNursing staffNUMEducator
Medical staffNursing staff
Failure of 12Lead ECGmachine
Unable to diagnose lifethreatening conditions
Ensure access to emergencypower
Use on battery power
Identify access to emergency poweroutlet
Keep batteries fully charged onemergency power
Identify location of alternative ECGmachines
Inform and educate staff
NUMEngineering staff
NUMNursing Staff
Nursing staff
NUM /Educator
A
A
A
A
Failure ofPulseoximeters
Unable to determineoxygen saturation
Increase nursing observationAccess other portable units fromfacility /Health Services ifavailable
Ensure staff to act as a runner areavailable
NUMEducator
B
Failure ofEmergencyAlarms
Unable to provide safeand secure environment
Increased staff vigilance
Refer to security plan
Schedule regular patient rounds
Direct notification via phone switch orrunner to Communication Centre tocontact fire services, security & police
Inform and Educate Staff
Nursing staff
All Staff
NUM
B
Failure of Patients unable to Refer to safety and security plan Have hand bells available NUM B
Page - 19 28/08/2013
MEDICAL AND SURGICAL WARDSA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICEPatient callbuttons
summon assistance
Failure ofinfusionPumps/SyringeDrivers
Staff unable to titratemedications and fluidsaccurately
Use battery power if available
Use burettes
Consider alternate administrationroutes
Charge on generator power if able Charge batteries fully Ensure adequate stock of burettes Protocols for alternative administration Manually titrate drip rate if necessary
All StaffNursing Staff
Nursing Staff
NUMMedical staff
A
AB
B
Failure ofEnteral feedpumps
Difficulty in maintainingpatient nutrition
Use alternate feeding methods Develop a procedure for bolus/gravityfeeding
Ensure adequate supply of tubes andfeeds
Manually titrate drip rate if necessary
Inform and educate staff
NUMEducator/Nursing staff
NUM
Educator
B
Failure ofSequentialCompressionDevices
Potential increased riskof DVT/Embolus
Use alternate methods ofdeterring thromboembolus
Identify at risk patients
Consider compression stockings/drugtherapy
Develop Policy Ensure adequate supplies of stockings
NUMMedical staff
NUM/EducatorMedical StaffNUM/EducatorMedical StaffNursing staff
C
Refrigeration Drugs and medicalsupplies requiringrefrigeration maybecome unusable
Place drugs in refrigerators whichare connected to emergencypower supply
Use eskies and ice
Review emergency power outlets Monitor refrigerator temperature with
thermometer
Consider purchase of eskies and supplyof ice
Inform and Educate Staff Consult with Pharmacy
NUMEngineering Staff
Nursing staffInfection Control Staff
NUM/Educator
A - B
Failure of Difficulties with lifting Identify alternate lifting devices Use hydraulic lifting devices if available C
Page - 20 28/08/2013
MEDICAL AND SURGICAL WARDSA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICELifting Devices heavy patients – manual
handling injuries Mobile power pack Use of ski sheets, bed sheets etc Ensure staff trained in manual handling
All Staff
Pan RoomHopper
Unable to clean bedpans/urinals correctly
Rinse with ‘grey/waste” water anddisinfect with chemical solution
Reinforce Infection Control Policy
All Staff
Infection Control CNCEducator
B
B
Lift Failure Unable to transportpatients to differentlevels within the facility
Ensure one lift operates onemergency power
Utilise alternate methods oftransporting patients
Consider utilising ground floorfacilities
Minimise patient transfers
Review existing supply of emergencypower
Walk patients
Consider scoop stretchers, fireblankets, stair walkers, cardboardstretchers
Develop facility plan for locating newadmissions
Critical transfers only
Ensure all staff aware of facilityFire/Evacuation plan
Engineering StaffDisaster Committee
WardspersonNursing staffMHHS Executive
MHHS Executive
Medical Staff
NUM
A
A
A
A
A
A
Failure ofVideo & TV
Negative Impact onpatienteducation/enjoyment
Verbal education
Alternative recreational activities
Develop alternate packages for patients Prepare mobile library Consider hand held games for children
NUMEducatorVolunteersMHHS ExecutiveNUM
C
Failure of Fax Unable to receive orsend patient information
Utilise alternate lines ofcommunicationScan and email
Send patient information via courier orrunner
Delay the transfer of information untilservices have resumed
NUM
Medical StaffAdministration staff
B
B
Failure ofcopier
Unable to copydocuments
Utilise alternate lines ofcommunication
Telephone information
Send the original documents with thepatient and document in the chart
Nursing staffMedical staff
Page - 21 28/08/2013
MEDICAL AND SURGICAL WARDSA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICEDelay the transfer of information untilservices have resumed
Staffing Increased manual tasksmay increase theworkload
Roster extra staff on duty
Place staff on call
Estimate staffing numbers for 24 hourperiod
Prepare rosters Liaise with agencies for extra staff Call in staff if possible
All Managers
EquipmentFunction
Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon as possibleafter disruption of power
Identify all equipment to be checked
Inform and Educate staff
NUMAll Staff
Educator
Page - 22 28/08/2013
Business Continuity Planning
Rehabilitation UnitThe Unit is connected to the emergency generator
REHABILITATION UNIT
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you
function without thisservice?
Failure ofinpatientelectric bedsmechanics
Unable to adjust heightof beds for safeexit/entry by patient
Utilise emergency generatorpower within 10 seconds ofpower failureIdentify alternative batterypower pack to operate bedmechanics
Identify emergency poweroutlets
Confer with engineering reavailability of portablebattery back-up equipment
All Nursing & Unit OperationalstaffNUM
D
Failure of VitalSigns Monitors& pulseoximetry
Nursing staff can utilisemanual equipment –minimal impact onnursing resources/time
Utilise emergency generatorpower within 10 seconds ofpower failureUtilise battery back upEnsure that nursing andmedical staff have access tomanual vital signsequipmentEnsure solid stock ofalkaline batteries forportable pulse oximetry unit
Identify emergency poweroutletsEnsure batteries are fullychargedEquipment nurse to ensurethat there is a sufficientsupply of correct sizedbatteries for equipment inunit storage.
All Nursing &Unit Operational staff
C*NB- Battery life of
Monitor is 30 mins to 2hours
ComputerSystem
Unable to access patientinformation systems andRehab Unitdocumentation if systemfails
D
Paging System Unable to contacttreating medical officerTeams if system fails-patient care mix at risk
D
Page - 23 28/08/2013
REHABILITATION UNIT
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you
function without thisservice?
Failure ofDefibrillator
Unable to defibrillatepatients
Utilise emergency generatorpower within 10 seconds ofpower failureUtilise battery back up
Utilise other availableDefibrillators
Identify emergency poweroutlets
Ensure batteries are fullychargedIdentify location of alternatedevices
All Nursing and Medical staffUtilise battery back up
Utilise other availableDefibrillators
Internal phonesystem
Unable to communicatewith others internally andexternally
Utilise personal mobilephones or ? available MBHmobile phone
Nurse CallAlarm System
Patients unable to buzzfor assistanceUnable to raise alarm foremergency and lifethreatening situations
Supply of hand bells
Use of phones if main phonesystem operational
Equipment nurse to ensuresupply and storageUse 222
Equipment Nurse & NUM
StaffingResources
Unable to provide safelevel of care in the eventof reduced nursingresources 24/7
Use Unit base staffing modelwhere possible.Seek support of thevolunteer services to assistwith tasks such as bed-makingConsider “outlieing” patientsto other departments if noteffected or transfer to otherfacilities/hospitals
Calculate individual patientstaffing requirements
Identify care staff able to beon call and redeployed in thefacilityEstimate staffing numbersrequired for 24 hour periodIdentify nursing staff able tobe on call and redeployed inthe facilityEstimate staffing numbersrequired for 24 hour periodEstimate staffing numbersrequired for 24 hour periodLiaise with other
Nurse Unit ManagerNurse ManagerNursing Director
Nurse Unit ManagerNurse ManagerNursing Director
Indefiantly but with alimited service
Page - 24 28/08/2013
REHABILITATION UNIT
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you
function without thisservice?
facilities/units for extra carestaffLiaise with agencies forextra staffCall staff in when required
Essentialequipmenti.e.HoistsDressings andstore supplies
Unable to maintaincontinuity of caremanagement
Ensure adequate supply instoresAccess from otherdepartments
Equipment Nurse & NUM A
Linen SuppliesUnable to maintainadequate linenmanagement if Laundryeffected - potentialinfection control risk
B
Food Supplies Unable to maintainadequate dietaryrequirements ofindividual patients ifkitchen area effected
Outsource food supplies andcateringTransfer patients to otherwards/units
A
Oxygendelivery system
Would have to rely oncylinder supply
Maintain adequate supply ofcylinder O2 and deliverydevices
Confer with engineering reavailability of additionalsupply in emergency event
NUMEquipment NurseEngineering Rep B
InadequateWasteCollection &Disposal
Build up of clinical andgeneral waste productsin unitInfection Control Issue
Page - 25 28/08/2013
Business Continuity Plan
Operating Theatre ServicesContinuity Plan based on having Emergency generator power to the unit. If no power at all operating would cease and cases would have to be transferred.Emergency phone Number if no power 6392
OPERATING THEATRE SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can youfunction without thisservice?
Failure ofcomputerisedbooking system
Unable to schedule /cancelpatients for surgery
Revert to manual process Utilise downtime forms
Consider use of Theatre logbook.
Administration staffC
Failure ofanaestheticmachines &ventilators
Loss of power to machine
Inaccurate delivery ofanaesthetic gases
Unable to ventilate patients
Run on emergencygenerator power .Run on gases if no powerOxygen driven) for 90minutes only. Monitor ptfor 40 minutes on batteryfrom PACU monitorsUse backup cylindersupplies of oxygen, nitrousoxide & airHand ventilate
Check access to emergencypower outlets.Manually ventilate.Manually physically assess
Ensure supplies of cylindergasses available
Ensure adequate supply ofhand operated ventilationequipment - Disposablemanual resuscitatorLocate and provide air /oxygen driven ventilator(oxylog)Cancel elective surgery
Nurse Unit ManagerAnaesthetic staff
Unit ManagerWards person
Unit ManagerAnaesthetic staff
Director of AnaestheticsDirector of SurgeryNurse Unit ManagerESC &DMS/DON/ND/EDMS
A
Failure of Monitors –cardiac oximetry,end tidal CO2
Unable to identify arrhythmias /oxygen saturation andproblems with ventilation
Run on emergencygenerator power Batteypower 40 minutes- One UPSwill operate for 5 hrs
Check access to emergencypower outlets
Identify & ensure adequatemedical & nursing staffcoverage
Unit ManagerAnaesthetic staff
Director of AnaestheticsCNC
A
Page - 26 28/08/2013
OPERATING THEATRE SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can youfunction without thisservice?
Defibrillator doesnot function
Unable to defibrillate patients Use on emergencygenerator power or batterypower.Use battery back up ifavailable
Check access to emergencypower outlets
Have batteries fully charged
Unit Manager
All staff
A
Failure oflaparoscopic camera/ light lead
Unable to performlaparoscopic surgery (may bedone if generator onemergency power).
Revert to non laparoscopicmethods
Postpone all non urgentsurgery
Notify surgeons, medical,nursing and booking office
Contact non urgent patientsand inform re need toreschedule at later dateensure list of proceduresunable to be under takenavailable at theatre frontdesk
Unit Manager
Bookings/OR Manager
Unit ManagerMedical staff
A
Failure of diathermymachine
Unable to perform electricalcoagulation (may be done ifgenerator on emergencypower).
Revert to ties/sutures Ensure adequate supply ofties and sutures
Unit Manager A
Failure of operatingtable.
Unable to position patient Revert to manual processes Adjust bed to optimal heightprior to critical datesPurchase manual overridefor table.Deleted all electric bed
Nursing staff
Nursing staffWards persons
A
Failure of Sterilisingequipment forscopes (ONEMERGENCYPOWER).
Unable to sterilise endoscopic/ laparoscopic and orthoscopicequipment
Consider open procedureswhere clinically indicated
Notify surgeons, medical,nursing and booking officeIdentify suitable patientsContact non urgent patientsand inform re need toreschedule at later dateStaff education – availabilityof types of cases able to bedoneList of procedures unable tobe under taken available attheatre desk
Unit ManagerMedical staff
Bookings/OR Manager
Unit ManagerOR Educator
Unit ManagerMedical staff
A
Page - 27 28/08/2013
OPERATING THEATRE SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can youfunction without thisservice?
Failure of Turbinetool outlets
Unable to use orthopaedicpower equipment:, Drills, Saw,Phaco Machine, Tourniquet
Use Tool air cylindersUse battery tools.
Ensure three full cylindersavailableEnsure CSSD rechargebatteries. In theatre poweroutlets
Wards personNUM
B
Failure of patientwarming devices
Unable to maintain patientthermal regulation
Revert to manual processes • Ensure supply of spaceblankets, warmingboots/gloves etc.
Nursing staffB
Failure of transportmonitors
Unable to monitor critically illor unstable patients
Aim to have at least onecompliant transport monitor
PACU Monitors portable &have battery powerCharge batteries
Biomedical staffUnit ManagerDuty staff
B
Failure of lift Unable to transport patientto/from theatre
Ensure one lift operates onemergency power
Review existing supply ofemergency power
Manager Engineering A
Relocate services Consider relocating onetheatre on ground floor (eg)in ED
MHHS Executive
Consider locating all surgicalpatients on same level asOperating Theatre.
MHHS ExecutiveDirector of Surgery
A
Staffing Unable to provide safe level ofcare in the event of equipmentfailure
Centralise surgical servicesat one site in MHHS overcritical periodsRoster additional staff
Develop a staffing plan forMHHS.
Calculate individual unitstaffing requirementsIdentify need to maintainstaff on site as opposed toon call.Identify human resourcesable to be on call andredeployed in the facilityAssess competence of oncall staff
Unit Manager Director ofSurgery
Unit ManagerDirector of Surgery
Unit ManagerNurse manager
Unit Manager
A
Equipment Function Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon aspossible after disruption ofpower
Identify all equipment tochecked
Inform and educate staff
Unit ManagerAll staff
A
Recovery Monitoring equipment not onpower.
Monitors have battery power Nurse Unit Manager A
Page - 28 28/08/2013
OPERATING THEATRE SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can youfunction without thisservice?
Staff unable tocome to work.
No available Staff to performlists.
Disaster Plan has allavailable phone numbers upto date.
NUM to ensure DisasterPlan is current
Nurse Unit Manager A
No lights in changerooms
Staff are unable to change toscrubs Staffmay not feel safe.
Torches are available in theunit.Security to inspect all areasbefore staff enter.
Ensure batteries are in unit.Arrange security inspection.
NUM C
Computer failure Unable to generate ID labels
Unable to track patient locationand bed status
Unable to accesscomputerisedpathology/radiology results
Revert to manual process
Enter data when systemfixed
Ensure supply of HBCISdowntime formsPre –print labels on existingpatientsHand write on blank labelsfor new admissionsUpdate patient location andbed status at regularintervalsNotify after-hours managerof all patient movementsDevelop a process fordisseminating patientupdates as part of the facilitycommunication planEnsure supply of pathologyresult formsDevelop means fornotification of lab & testresultsManual ordering testsEnsure retrospective dataentry when computerservices resumeBackup any non centraliseddata or ward specificcomputer programs
Administrative and nursing staff
Nursing staff
Nursing Staff Team Leader
Medical & nursing staffUnit Manager & Lab staff
Administrative staff
Power failure Mains power not available Refer to mains power failureplan
Inform and educate staff Unit Manager /Nurse Educator
Lighting failure Difficulties in patientobservation and care.
Utilise emergency lighting .Torches in all anaestheticmachines.
Identify provision foremergency lighting
Engineering staffNurse Unit Manager
Page - 29 28/08/2013
OPERATING THEATRE SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can youfunction without thisservice?
Increased risk for patients andstaff
Maximise natural lighting
Utilise alternate lighting
Maintain WH&S precautionsRefer to Facility wide powerfailure plan
Relocate immobile patientsto best lit areasClean and maintain windowsand fittingsEnsure blinds/curtains openEnsure adequate supplytorches / battery operatedlights and batteriesClear patient areas, workareas and corridors of allhazardsEducate staff
Nursing staff
Cleaning staff
Unit Manager
Air conditioningfailure
Unable to regulatetemperature and environmentUnable to perform surgery dueto risk of infectionPossible loss of sterile stockdue to high temps.
Open Windows wherepossible.Electrical or manual fan
Refer to facility wide plan
Position fans for maximumbenefitIdentify patients requiringcoolingInform and educate staff
Nursing staff
Telephone failure No internal / externaltelephone communications.
Refer to facility widetelecommunications plan
Inform and educate staff Unit ManagerShift Team Leader /Educator
Wall oxygen supplyfailure.
Wall oxygen not available Use cylinder oxygen Identify anticipatedrequirements of cylinderoxygen for ward patientsOrder required cylindersfrom central storage areaEnsure correspondingnumber of oxygen fittingsavailable at ward level.Ensure all staff educated incylinder changeoverConsider co-locating highoxygen users
Unit Manager
Wards person
Wards personUnit Manager /EducatorNursing staffMedical Staff
Page - 30 28/08/2013
OPERATING THEATRE SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can youfunction without thisservice?
Wall suction failure Wall suction not available Use alternate suctiondevices
Provide emergencyoxygen/suction
Assess need for and numberof portable suction unitsrequired (There is twoportable suction unit in thetheatre).Consider co-locating suctiondependent patientsEnsure adequate supplyalternate drainage systemsReplace drain suction withmanual vacuum or drainagebottlesEnsure small oxygencylinder with twin-o-vacsuction on resuscitationtrolleyEducate staff on use ofalternate devicesUse weighted scales ifavailable
Unit Manager
Nursing staff
Nursing staff
Unit ManagerEducator
Unit Manager
Failure of Tympanicthermometer
Potential for inaccuracy oftemperature readings
Use digital thermometer Ensure stock digitalthermometers
Unit Manager
Failure of non-invasive bloodpressure (NIBP)monitors
Unable to electronicallymeasure blood pressurerecordings
Use manualsphygmomanometer
Ensure adequate number ofmanualsphygmomanometers
Unit Manager
Failure ofGlucometer
Potential for decreasedaccuracy in blood glucosereadings
Visual readings
Formal laboratory bloodglucose analysis forabnormal results
Ensure adequate stock ofbatteries.Inform and educate staffDevelop policy for formallaboratory test
Nursing staffUnit ManagerEducatorMedical staff
Failure of 12 leadECG machine
Unable to diagnose potentiallife-threatening conditions
Ensure access toemergency powerUse on battery power
Identify access toemergency power outletKeep batteries fully chargedon emergency powerIdentify location ofalternative ECG machinesInform and educate staff
Unit ManagerEngineering staffNursing StaffEducator
Page - 31 28/08/2013
OPERATING THEATRE SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can youfunction without thisservice?
Failure of Pulseoximeters
Unable to determine oxygensaturation
Increase nursingobservation
Educate staff re basicphysical assessment ofpatient
Unit ManagerEducator
Failure of LamsonSystem
Unable to transport specimens Revert to manual process Inform and educate staff Unit ManagerEducator
Failure ofEmergency Alarms
Unable to provide safe andsecure environment
Increased staff vigilance Schedule regular patientroundsDirect notification via phoneto switch or runner toCommunication Centre tocontact fire services,security, police
Nursing staff
Refer to safety and securityplan.
Inform and educate Staff Unit Manager
Failure of Patientcall buttons
Patients unable to summonassistance
Refer to safety and securityplan.
Inform and educate staff Unit Manager
Failure of InfusionPumps/SyringeDrivers
Staff unable to titratemedications and fluidsaccurately
Use on battery power ifavailableUse burettes
Consider alternateadministration routes
Charge on generator powerif able Charge batteries fullyEnsure adequate stockburettesProtocols for alternativeadministration
All staff Nursing staff
Medical staff
A
Failure of Enteralfeed pumps
Difficulty in maintaining patientnutrition
Use alternate enteralfeeding methods.
Develop procedure for bolus/ gravity feedingEnsure adequate supplytubes & bags & feedsInform and educate staff
Unit ManagerEducatorNursing Staff
Failure of SequentialCompressionDevices
Potential increased risk of DVT/Embolus
Use alternative methods ofdeterring thrombo-embolus
Identify at risk patients
Consider compressionstockings/ drug therapyDevelop policyEnsure adequate supplies ofstockings
Unit ManagerMedical staffEducator
Page - 32 28/08/2013
OPERATING THEATRE SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can youfunction without thisservice?
Refrigeration(Connected toEmergency power).Alert staff if noemergency power tomake plans forrefrigerated drugs.
Drugs and medical suppliesrequiring refrigeration maybecome unusable
Place drugs in refrigeratorswhich are connected toemergency power supply
Use Eskies and ice
Review emergency poweroutletsMonitor refrigeratortemperature withthermometerConsider purchase of eskiesand supply of iceConsider purchase of eskiesand supply of iceInform and educate staffConsult with Pharmacy
Unit ManagerEngineering staffNursing staffInfection Control Staff
Failure of liftingdevices
Difficulties with lifting heavypatients – manual handlinginjuries
Identify alternate liftingdevices
Use hydraulic lifting devicesif availableUse of ski sheets, bedsheets, etc.Ensure staff trained inmanual handling
All staff
Unit ManagerEducator
Pan room hopper Unable to clean bed pans /urinals adequately
Single patient use bedpans/urinals
Purchase sufficient forimmobile patientsRinse with “grey/waste”water and disinfect withchemical solution• Rinsewith “grey/waste” water anddisinfect with chemicalsolutionInform staff of InfectionControl policy
Unit Manager
All staff
Unit ManagerInfection Control CNC
Lift failure Unable to transport patients todifferent levels within facility
Ensure one lift operates onemergency powerUtilise alternate methods oftransporting patients
Consider utilising groundfloor facilitiesMinimise patient transfers
Review existing supply ofemergency powerWalk patients
Consider scoop stretchers,fire blankets, stair walkers,cardboard stretchersDevelop facility plan forlocating new admissionsCritical transfers onlyEnsure all staff aware offacility Fire / Evacuation plan
Engineering staffDisaster CommitteeWards person
MHHS Executive
Medical staffUnit Manager
Page - 33 28/08/2013
OPERATING THEATRE SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can youfunction without thisservice?
Failure of Fax Unable to receive or sendpatient information
Utilise alternate lines ofcommunication
Send patient information byrunner/courierDelay transfer of informationuntil services resumed.
Unit Manager
Medical staffAdmin. staff
Failure of Copier Unable to copy documents Utilise alternate lines ofcommunication
Telephone informationSend original documentswith patient and document inchartDelay transfer of informationuntil services resumed
Nursing staffMedical staff
Staffing Increased manual tasks mayinfluence workload
Roster extra staff on duty
Place staff "on call"
Estimate staffing numbersrequired for 24 hour periodPrepare rostersLiaise with agencies forextra staffCall in staff
All managers
Duty managers
Equipment Function Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon aspossible after disruption ofpower
Identify all equipment to bechecked
Inform and educate staff
Unit ManagerAll staff
DMHHS ExecutiveUnit Manager /Educator
Page - 34 28/08/2013
Business Continuity Planning
Intensive Care UnitThe Unit is connected to the emergency generatorNote: The Standard Operating Procedures for the general wards and the MHHS Essential Services are to be used in conjunction with thespecific procedures detailed below.
INTENSIVE CARE UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
Problem Impact Contingency Task Responsibility How long can you function without this service?
Failure ofCentralMonitoringSystem
Unable to closelymonitor patientsfrom centralstation
Utiliseemergencygenerator powerwithin 10seconds ofpower failure
Identifyemergencypower outlets
All Nursing and Medical staff
Use bedsidemonitors
Ensure alarmsfunctional andturned "on" on allmonitors
Nursing staff
Initiate closeobservation ofpatients
All Nursing and Medical staff
Unable toprovideTelemetry togeneral wards
Assess need forward patients tobe on Telemetry
Use portablemonitoringdevices on thewards
Director ICU, Medical Consultants and Nurse Unit Mangers
Transfer at riskpatients toICU/CCU
Medical Staff, NUM and team Leader
Failure ofMonitorsincludingcardiac &oximetry
Unable toidentifyarrhythmia’s /oxygensaturation
Utiliseemergencygenerator powerwithin 10seconds ofpower failure
Identifyemergencypower outlets
All Nursing and Medical staff
Utilise batteryback up
Ensure batteriesare fully charged
Nursing staff Battery life of Monitor is 30 mins to 2 hours
Locatefunctioningportablemonitors
Prioritise patientsfor monitoring
Director of ICU and ICU Consultants
Page - 35 28/08/2013
INTENSIVE CARE UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
Problem Impact Contingency Task Responsibility How long can you function without this service?
Increasednursing &medicalobservation
Inform staff All Nursing and Medical staff
Increasedrostered staffingnumbers
NUM Depening on staff availability
Utiliseemergencysupply ofporatble SpO2monitors
PurchaseportableemergencySpO2 monitorsfor eachICU/CCU bed
NUM
Note: Monitors work on emergency power. There are three portable Lifepacks and two transport monitor in the unit if emergency power does not work.
Failure ofTransportmonitors
Unable tomonitor criticallyill or unstablepatients
Utilise batterypower
Ensurebatteriesare fullycharged andoperational
Nursing staff Battery life of Monitor is 30 mins to 2 hours
Limit anymovement ofthese patients toessential testsonly
Liaise withMedical Officerregarding needfor patienttransfer
All Nursing and medical staff
Utiliseemergencysupply ofporatble SpO2monitors
Identify locationof emergencysupply
All Nursing and Medical staff
Failure ofDefibrillator
Unable todefibrillatepatients
Utiliseemergencygenerator powerwithin 10seconds ofpower failure
Identifyemergencypower outlets
All Nursing and Medical staff
Utilise batteryback up
Ensure batteriesare fully charged
All nursing and Medical staff
Utilise otheravailable
Identify locationof alternate
All nursing and Medical staff
Page - 36 28/08/2013
INTENSIVE CARE UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
Problem Impact Contingency Task Responsibility How long can you function without this service?
Defibrillators devices
Insufficientstaff
Unable toprovide safelevel of care inthe event ofequipment failure
Use Unit basestaffing modelwhere possible.
Calculateindividual patientstaffingrequirements
Director of ICU,ICU Consultants,NUM and TeamLeader
Indefiantly but with a limited service
Identify criticalcare staff able tobe on call andredeployed in thefacility
NUM and Team Leader
Estimate staffingnumbersrequired for 24hour period
NUM and Team Leader
Liaise with otherfacilities for extracritical care staff
NUM
Liaise withagencies forextra critical carestaff
NUM
Call staff in whenrequired
NUM, Nurse Manager and Team Leader
Transfer patientsto other facilities
NUM and Clinical Director
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Business Continuity Planning
Coronary Care UnitThe Unit is connected to the emergency generatorNote: The Standard Operating Procedures for the general wards and the MHHS Essential Services are to be used in conjunction with thespecific procedures detailed below.
CORONARY CARE UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
Problem Impact Contingency Task Responsibility How long can you function without this service?
Failure ofCentralMonitoringSystem
Unable to closelymonitor patientsfrom centralstation
Utiliseemergencygenerator powerwithin 10seconds ofpower failure
Identifyemergencypower outlets
All Nursing and Medical staff
Use bedsidemonitors
Ensure alarmsfunctional andturned "on" on allmonitors
Nursing staff
Initiate closeobservation ofpatients
All Nursing and Medical staff
Unable toprovideTelemetry togeneral wards
Assess need forward patients tobe on Telemetry
Use portablemonitoringdevices on thewards
Director ICU, Medical Consultants and Nurse Unit Mangers
Transfer at riskpatients toICU/CCU
Medical Staff, NUM and team Leader
Failure ofMonitorsincludingcardiac &oximetry
Unable toidentifyarrhythmia’s /oxygensaturation
Utiliseemergencygenerator powerwithin 10seconds ofpower failure
Identifyemergencypower outlets
All Nursing and Medical staff
Utilise batteryback up
Ensure batteriesare fully charged
Nursing staff Battery life of Monitor is 30 mins to 2 hours
Locatefunctioningportablemonitors
Prioritise patientsfor monitoring
Director of ICU and ICU Consultants
Page - 38 28/08/2013
CORONARY CARE UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
Problem Impact Contingency Task Responsibility How long can you function without this service?
Increasednursing &medicalobservation
Inform staff All Nursing and Medical staff
Increasedrostered staffingnumbers
NUM Depening on staff availability
Utiliseemergencysupply ofporatble SpO2monitors
PurchaseportableemergencySpO2 monitorsfor eachICU/CCU bed
NUM
Note: Monitors work on emergency power. There are three portable Lifepacks and two transport monitor in the unit if emergency power does not work.
Failure ofTransportmonitors
Unable tomonitor criticallyill or unstablepatients
Utilise batterypower
Ensure batteriesare fully chargedand operational
Nursing staff Battery life of Monitor is 30 mins to 2 hours
Limit anymovement ofthese patients toessential testsonly
Liaise withMedical Officerregarding needfor patienttransfer
All Nursing and medical staff
Utiliseemergencysupply ofportable SpO2monitors
Identify locationof emergencysupply
All Nursing and Medical staff
Failure ofDefibrillator
Unable todefibrillatepatients
Utiliseemergencygenerator powerwithin 10seconds ofpower failure
Identifyemergencypower outlets
All Nursing and Medical staff
Utilise batteryback up
Ensure batteriesare fully charged
All nursing and Medical staff
Utilise otheravailableDefibrillators
Identify locationof alternatedevices
All nursing and Medical staff
Page - 39 28/08/2013
CORONARY CARE UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
Problem Impact Contingency Task Responsibility How long can you function without this service?
Insufficientstaff
Unable toprovide safelevel of care inthe event ofequipment failure
Use Unit basestaffing modelwhere possible.
Calculateindividual patientstaffingrequirements
Director of ICU,ICU Consultants,NUM and TeamLeader
Indefinite but with a limited service
Identify criticalcare staff able tobe on call andredeployed in thefacility
NUM and Team Leader
Estimate staffingnumbersrequired for 24hour period
NUM and Team Leader
Liaise with otherfacilities for extracritical care staff
NUM
Liaise withagencies forextra critical carestaff
NUM
Call staff in whenrequired
NUM, Nurse Manager and Team Leader
Page - 40 28/08/2013
Business Continuity Plan
Women’s HealthThe Birth Suites are connected to the Emergency Generator
WOMENS HEALTH UNIT
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Failure of Infantresuscitation trolleys
Suction and oxygen notimmediately available
Unable to maintain infantwarming
Use portable gases
Use emergency generatorpower
Ensure alternate warmingdevices availableFill Blanket warmer withblankets and linen andplugged into generatorDry babies well. Wrap &dress warmlyPlace baby in bed withmother
Ensure twin-o-vac available
Ensure oxygen and ircylinders on resus cots arefull and additional bottles areavailableEnsure trolleys are pluggedinto red emergency powerpoints.Ensure supply of linen,blankets and bubble wrap
Consider bubbie wrap,space blankets, gladwrap
Clinicians
Unit Manager
Clinicians
Unit ManagerWardsperson
Nursing staff
Nursing staff
A
Failure of electric deliverybeds
Positioning for anassisted birth moredifficult
Use emergency generatorpower
Revert to manualpositioningInform staff & patients
Ensure trolleys are pluggedinto red emergency powerpoints.Adjust bed to optimal heightprior to critical dates
Clinicians
Nursing staffWardspersons
C
Failure ofCardiotocograph (CTG)/pH scalp monitoring
Unable to performcontinuous foetal heartmonitoring on high riskwomen
Use emergency generatorpower
Use battery-poweredultrasound doppler.
Use Pinard stethoscope
Ensure trolleys are pluggedinto red emergency powerpoints.Identify at risk patients &instigate intermittentmonitoringEnsure adequate supply ofbattery operated dopplersand gel.Ensure access to Pinard
Clinicians
Unit ManagerMedical staff
Unit Manager
C
D
Page - 41 28/08/2013
WOMENS HEALTH UNIT
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
stethoscopeEducate staff in use
Medical staff
Failure of Monitorsincluding cardiac &oximetry
Unable to identifyarrhythmias / oxygensaturation
Utilise emergencygenerator power
Utilise battery back up
Locate functioning monitors
Increased nursing &medical observation
Identify emergency poweroutlets
Ensure batteries fullychargedPrioritise patients formonitoringInform and educate staff&patients
Unit ManagerEngineering staff
Nursing staff
Medical staffNursing staff
A
Potential for complicateddelivery
Unable to provideappropriate level of carein the intrapartum period
Transfer to other centres
Discuss options withpatient.Transfer patient beforecritical period
Early assessment andidentification of at risk clients
Medical staff
Medical staffNursing staff
D
Staffing Unable to provide safelevel of care.
Utilise staff available withinthe facilityPlan staffing availability
Calculate individual unitstaffing requirementsIdentify pool of appropriatelyskilled staff to be on calland/or redeployed in thefacility
Unit ManagerMedical Director
Unit ManagerMedical Director
D
Lift failure Unable to transportpatient to theatre orlabour ward
Ensure one lift operates onemergency power
Consider alternate area forCaesarean section
Review exisitng supply ofemergency power.
Designate an area
Develop unit policies forprocedure, personnel, andequipmentInform and educate staff &patients
MHHS ExecutiveEngineering staff
MHHS ExecutiveMedical staffNursing staff
Unit ManagerMedical DirectorEducator
A
A
Equipment Function Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon aspossible after disruption ofpower
Identify all equipment to bechecked
Inform and educate staff
Unit Manager
MHHS ExecutiveMedical staffNursing staff
ADEPENDS ONEQUIPMENT
Page - 42 28/08/2013
Business Continuity PlanSpecial Care Neonatal Intensive Care Nursery
Special Care Nursery is connected to Emergency PowerRisk Management regular checks of emergency equipment and processes
SPECIAL CARE – NEONATAL INTENSIVE CARE NURSERY
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Failure of ventilators Deterioration / possibledeath of critically illventilated neonates
Run ventilators onemergency power
Run ventilators on batteryback up (limited backup life)
Use alternative respiratorysupport methods eg BubbleCPAP
Hand bagging
Check emergency poweroutlets
Ensure batteries arecharged at all times.Discuss with paediatrician rereview of critically ill patientsand ventilation options theneed to transfer at riskbabies where possible.In-service all staff onoperation of respiratorysupportYearly competency.Ensure rostered staff arecompetent
Unit ManagerEngineering staff
Clinical StaffMedical Staff
Unit ManagerMedical DirectorEducator
A
Failure of Humidicrib Difficulty in regulatingneonate's environment
Use emergency generatorpower
Review of ambienttemperatureUse warm blankets and/orjump suitsUse bubble wrap
Use water bed ifemergency power
Ensure cribs are pluggedinto red emergency powerpoints.Adjust bedding and clothingto meet neonatal needsEnsure adequate supply ofblankets/jump suitsEnsure supply of bubblewrapClinician to plan best optionrelative to clinical needs ofbaby.Inform and educate staff
All Clinicians
Unit ManagerEducator
A
A
Failure of phototherapyunit
Unable to correctjaundice
Utilise emergency power
Monitor Bilirubin levels
Ensure access toemergency powerTransfer to another centre ifclinical care requires
Unit ManagerEngineering staffNursing StaffMedical staff
Aas long as contingency
available
Page - 43 28/08/2013
SPECIAL CARE – NEONATAL INTENSIVE CARE NURSERY
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Exchange transfusioninterventionTransfer to another centre ifclinical care requiresintervention that cannot besafely performed in the SCNat the time.
Nursing StaffMedical staff
Failure of Monitorsincluding cardiac &oximetry
Unable to identifyarrhythmias / oxygensaturation
Utilise emergencygenerator powerUtilise battery back up
Locate functioning monitors
Increased nursing &medical observation
Identify emergency poweroutletsEnsure batteries fullychargedPrioritise patients formonitoringInform and educate staff
Unit ManagerEngineering staff
Nursing staffMedical staff
A
Staffing Unable to provide safelevel of care in the eventof critical event
Utilise staff available withinthe facility
Plan staffing availability
Calculate individual unitstaffing requirements
Identify pool of appropriatelyskilled staff to be on calland/or redeployed in thefacility
Unit ManagerMedical Director
D
Equipment Function Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon aspossible after disruption ofpower
Identify all equipment to bechecked
Inform and educate staff
Unit Manager A
Failure of InfusionPumps/Syringe Drivers
Staff unable to titratemedications and fluidsaccurately
Use emergency generatorpower
Use on battery power ifavailableUse burettes
Consider alternateadministration routes.
Ensure pumps are pluggedinto red emergency powerpoints.Charge on generator powerif able Charge batteries fullyEnsure adequate stockburettesProtocols for alternativeadministration
All staff Nursing staff
Nursing staff Medical staff
C
Failure of Breast Pump(Minimal significance)
Unable to express breastmilk
Use emergency generatorpowerExpress by hand or manualpumps
Ensure pumps are pluggedinto red emergency powerpoints.Adequate supplies ofmanual breast pumps
Nursing staff
Unit Manager
C
Page - 44 28/08/2013
SPECIAL CARE – NEONATAL INTENSIVE CARE NURSERY
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Inform and educate staffInform and educate patients
Unit ManagerEducator
Refrigeration of formula &expressed breast milk(EBM)
EBM & formula maybecome contaminated
Use emergency generatorpower
Use fresh EBM
Use frozen EBM
Ensure date and time ofdefrosting is marked on anyEBMUse of formula instead offrozen EBM as a last resortonly.Use pre packed formulathat does not requirerefrigeration
.Ensure fridge is pluggedinto emergency supplyObtain EBM as close to feedas possibleDiscard any defrosted EBMafter 24hrs.Discard unused EBM after24hrs
Discuss options with motherEnsure adequate stocks ofbottled sterile water andformula (powder & prepared)Formula made and used asrequiredDiscard unused formulaDevelop unit policy andeducate staffConsult with Pharmacy
Nursing staff
Nursing staffMothers
Nursing staffInfection Control Staff
Unit ManagerEducator
C
Page - 45 28/08/2013
Business Continuity PlanWomens Health Unit – Ward & Clinics
WOMENS HEALTH UNIT - WARD & CLINICS
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Computer failure Unable to generate IDlabels
Unable to track patientlocation and bed status
Unable to provide patientdietary requirements
Unable to recordinformation relating topatient nursedependencyUnable to accesscomputerisedpathology/radiologyresults
Record patient detailsmanually
Revert to manual process
Revert to manual process
Revert to manual process
Revert to manual process
Enter data when systemfixed
Ensure supply of HBCISdowntime formsPre –print labels on existingpatientsHand write on blank labelsfor new admissionsUpdate patient location andbed status at regularintervalsNotify after-hours managerof all patient movementsDevelop a process fordisseminating patientupdates as part of the facilitycommunication planUpdate patient diet lists andhave available for collectionby catering servicesEnsure supply of downtimeforms available to recordinformation
Ensure supply of pathologyresult forms
Develop means fornotification of lab & testresultsManual ordering testsEnsure retrospective dataentry when computerservices resumeBackup any non centraliseddata or ward specific
Administrative StaffNursing Staff
Nursing Staff Team Leader
Unit Manager
Administrative staff
Administrative staff
Unit Manager & Lab staff
Medical & nursing staffUnit Manager & Lab staff
Administrative staff
A
A
A
A
Page - 46 28/08/2013
WOMENS HEALTH UNIT - WARD & CLINICS
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
computer programs
Power failure Mains power notavailable
Refer to mains powerfailure plan
Inform and educate staff Unit Manager /Nurse Educator A
Lighting failure Difficulties in patientobservation and care
Increased risk forpatients and staff
Utilise emergency lighting
Maximise natural lighting
Ensure blinds/curtains openUtilise alternate lighting
Maintain WH&Sprecautions
Refer to Facility wide powerfailure plan
Identify provision foremergency lightingRelocate immobile patientsto best lit areasClean and maintain windowsand fittingsEnsure adequate supplytorches / battery operatedlights and batteriesClear patient areas, workareas and corridors of allhazardsEducate staff
Engineering staff
Nursing staff
Cleaning staff
All staffUnit Manager
D
Air conditioning failure Unable to regulatetemperature andenvironment
Use alternate coolingdevices (eg.) Electrical ormanual fan
Refer to facility wide plan
Position fans for maximumbenefitIdentify patients requiringcoolingInform and educate staff
Nursing staff
A
Telephone failure No internal / externaltelephonecommunications
Refer to facility widetelecommunications plan
Inform and educate staff Unit ManagerShift Team LeaderEducator
A
Wall oxygen supply failure Wall oxygen notavailable
Use cylinder oxygen Identify anticipatedrequirements of cylinderoxygen for ward patientsOrder required cylindersfrom central storage area.Ensure all oxygen cylindersfullEnsure correspondingnumber of oxygen fittingsavailable at ward level.Ensure all staff educated incylinder changeover.
Unit Manager
Wardsperson
WardspersonUnit ManagerEducator
A
Page - 47 28/08/2013
WOMENS HEALTH UNIT - WARD & CLINICS
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Consider co-locating highoxygen users
Wall suction failure Wall suction notavailable
Use alternate suctiondevices
Provide emergencyoxygen/suction
Assess need for and numberof portable suction unitsrequiredConsider co-locating suctiondependent patientsEnsure adequate supplyalternate drainage systemsReplace drain suction withmanual vacuum or drainagebottlesEnsure small oxygencylinder with twin-o-vacsuction on resuscitationtrolleyEducate staff on use ofalternate devicesUse weighted scales ifavailable
Nursing staffMedical Staff
Unit ManagerEducator
A
Failure of noninvasiveblood pressure (NIBP)monitors
Unable to electronicallymeasure blood pressurerecordings
Run on emergency powerif loads permit.Use manualsphygmomanometer
Check emergency poweroutletsEnsure adequate number ofmanualsphygmomanometers
Unit ManagerEngineering staffUnit Manager
C
Failure of Pulse oximeters Unable to determineoxygen saturation
Increase nursingobservation
Educate staff re basicphysical assessment ofpatient
EducatorA
Failure of Lamson System Unable to transportspecimens
Revert to manual process Inform and educate staff Unit ManagerEducator
C
Failure of EmergencyAlarms
Unable to provide safeand secure environment
Refer to safety and
Increased staff vigilance Schedule regular patientroundsDirect notification via phoneto switch or runner toCommunication Centre tocontact fire services,security, policeInform and educate Staff
Nursing staff
All staff
D
Page - 48 28/08/2013
WOMENS HEALTH UNIT - WARD & CLINICS
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
security plan.
Failure of Patient callbuttons
Patients unable tosummon assistance
Refer to safety and securityplan
Inform and educate staff Unit Manager A
Staff unable to titratemedications and fluidsaccurately
Use on battery power ifavailable
Use burettes
Consider alternateadministration routes
Charge on generator powerif able Charge batteries fully
Ensure adequate stockburettesProtocols for alternativeadministration
All staff Nursing staff
Nursing Staff
Nursing staffMedical staff
C
Refrigeration Drugs and medicalsupplies requiringrefrigeration maybecome unusable
Place drugs in refrigeratorswhich are connected toemergency power supply
Use Eskies and ice
Review emergency poweroutlets
Monitor refrigeratortemperature withthermometer as per InfectionControl Guidelines.Consider purchase of eskiesand supply of iceInform and educate staffConsult with Pharmacy
Unit ManagerEngineering staff
Nursing staffInfection Control Consultant
Unit Manager
Unit ManagerEducator
A
Pan room hopper Unable to clean bedpans / urinals adequately
Single patient use bedpans/urinals
Purchase sufficient forimmobile patientsRinse with “grey/waste”water and disinfect withchemical solutionInform staff of InfectionControl policy
Unit Manager
Infection Control CNC
C
Lift failure Unable to transportpatients to differentlevels within facility
Ensure one lift operates onemergency power
Utilise alternate methods oftransporting patients
Review existing supply ofemergency power
Walk patients
Consider scoop stretchers,fire blankets, stair walkers,cardboard stretchers
Engineering staffDisaster Committee
Wardsperson
MHHS ExecutiveD
Page - 49 28/08/2013
WOMENS HEALTH UNIT - WARD & CLINICS
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Consider utilising groundfloor facilitiesMinimise patient transfers
Develop facility plan forlocating new admissionsCritical transfers onlyEnsure all staff aware offacility Fire / Evacuation plan
MHHS Executive
Medical staff
Unit ManagerFailure of Fax Unable to receive or
send patient informationUtilise alternate lines ofcommunication
Send patient information byrunner/courierDelay transfer of informationuntil services resumed
Unit Manager
Medical staffAdministration staff
B
Failure of Copier Unable to copydocuments
Utilise alternate lines ofcommunication
Telephone information
Send original documentswith patient and document inchartDelay transfer of informationuntil services resumed
Nursing staffMedical staff
Nursing staffMedical staff
B
B
Staffing Increased manual tasksmay influence workload
Roster extra staff on duty
Place staff "on call"
Estimate staffing numbersrequired for 24 hour periodPrepare rostersLiaise with agencies forextra staffCall in staff
All managers
Duty managers
D
Equipment Function Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon aspossible after disruption ofpower
Identify all equipment to bechecked
Inform and educate staff
Unit ManagerAll staff
MHHS ExecutiveUnit ManagerEducator
ADEPENDS ONEQUIPMENT
Page - 50 28/08/2013
Business Continuity PlanBirth Centre
The Birth Centre has no emergency power connected.The lighting is not suitable for operation without power
BIRTH CENTRE
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
No emergency power No electrical oremergency equipmentwill work.Poor lighting
Unable to provide infantwarming
Transfer all women to theWomen's health Unit
Transfer all women to theWomen's Health Unit
Transfer all women to theWomen's Health Unit
Arrange transfer of allwomen who require ongoingcare.Arrange transfer of allwomen who require ongoingcare.Arrange transfer of allwomen who require ongoingcare.
Unit ManagerBirth Centre Midwives
D
Isolation and Safety ofbuilding
Unable to maintaincommunication or safetyof staff
Transfer program to WHU Send P/N women home.Transfer to WHUB/C Midwives to providecare for BC women wherepossible.Inform all women that theservice is being conductedfrom the WHU for theduration of the disaster.Inform switchInform After HoursCoordinators
Unit ManagerBirth Centre Midwives
D
Outside furniture and toys Flying objects Refer to cyclonepreparation policy
Ensure all flying objects aresecure
Wards persons
Page - 51 28/08/2013
Business Continuity Planning
Child & Adolescent Health Unit
The following Standard Operating Procedures have been generated for application across clinical units where common processes exist and aregrouped thus to avoid replication of tasks for contingency planning for individual wards.
CHILD & ADOLESCENT HEALTH UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITYHOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICE?
Computerfailure
Unable to generate IDlabels
Record patient details manually Ensure supply of HBCIS downtime forms Administrative and nursing staff
CCan function but verytime consuming
Pre –print labels on existing patients Administrative and nursing staff
CCan function but verytime consuming
Hand write on blank labels for new admissions
Administrative and nursing staff
CCan function but verytime consuming
Unable to track patientlocation and bed status
Revert to manual process Update patient location and bed status at regular intervals
Administrative and nursing staff
CCan function
Notify after-hours manager of all patient movements
Nursing staff
C Can function
Develop a process for disseminating patient updates as part of the facility communicationplan
Nursing Staff TeamLeader
C Can functionUnable to provide patientdietary requirements
Revert to manual process Update patient diet lists and have available for collection by catering services
Unit Manager
CCan function but verytime consuming
Page - 52 28/08/2013
CHILD & ADOLESCENT HEALTH UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITYHOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICE?
Unable to recordinformation relating topatient nurse dependency
Revert to manual process Ensure supply of downtime forms available to record informationNursing staff to feedback to NUM/BedManager
Administrative and nursing staff
CCan function but verytime consuming
Unable to accesscomputerisedpathology/radiologyresults
Revert to manual process Ensure supply of pathology result forms Administrative staff
CCan function but verytime consuming
Develop means for notification of lab & test results
Unit Manager & Lab staff CCan function but verytime consuming
Manual ordering tests Medical & nursing staff CMO Currently write out
pathology forms Enter data when system fixed Ensure retrospective data entry when
computer services resumeUnit Manager & Lab staff
C Will be very timeconsuming
Backup any non centralised data or wardspecific computer programs
Administrative staff
C Will be very timeconsuming
Power failure Mains power not available Refer to mains power failure plan Inform and educate staff Unit Manager /Nurse Educator
BCan function in mostareas, dependent onpatient acuity
Lightingfailure
Difficulties in patientobservation and care.
Utilise emergency lighting Identify provision for emergency lighting Engineering staff BCan function in mostareas.
Relocate immobile patients to best lit areas Nursing staff BCan function in mostareas.
Maximise natural lighting Clean and maintain windows and fittings Cleaning staff BCan function in mostareas.
Ensure blinds/curtains open All staff BCan function in most
Page - 53 28/08/2013
CHILD & ADOLESCENT HEALTH UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITYHOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICE?
areas.
Utilise alternate lighting Ensure adequate supply torches / battery operated lights and batteries
Unit Manager
B Can function in mostareas.
Increased risk for patientsand staff
Maintain WH&S precautions Clear patient areas, work areas andcorridors of all hazards
Unit Manager /All staff B Can function in mostareas.
Refer to Facility wide powerfailure plan
Educate staff Educator B Can function in mostareas.
Airconditioningfailure
Unable to regulatetemperature andenvironment
Use alternate cooling devices(eg.)
Position fans for maximum benefit Nursing staff A Especially in summerLimited where nowindow.
Electrical or manual fan AEspecially in summerLimited where nowindow.
Identify patients requiring cooling Nursing staff AEspecially in summerLimited where nowindow.
Refer to facility wide plan Inform and educate staff Unit Manager AEspecially in summerLimited where nowindow.
Telephonefailure
No internal / externaltelephonecommunications .
Refer to facility widetelecommunications plan
Inform and educate staff Unit Manager /Shift Team Leader /Educator
AOnly for a limited time.Major impact onemergencycommunication from/toCAU in current position
Wall oxygensupply failure.
Wall oxygen not available Use cylinder oxygen Identify anticipated requirements of cylinder oxygen for ward patients
Unit Manager BNeed to increase to fourcylinders
Page - 54 28/08/2013
CHILD & ADOLESCENT HEALTH UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITYHOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICE?
Order required cylinders from central storage area.
Unit Manager
B Ensure all oxygen cylinders full Wards person
B Ensure corresponding number of oxygen
fittings available at ward level.Wards person B
Ensure all staff educated in cylinderchangeover.
Wards person/UnitManager /Educator
B
Consider co-locating high oxygen users Nursing staff /medical Staff
BPaediatric patients needto stay where there arepaediatric nurses
Wall suctionfailure
Wall suction not available Use alternate suction devices Assess need for and number of portablesuction units required
Unit Manager BNot safe for high riskpatients. Area only hasone manual suction.Post operative patientsnot able to cared forsafely.
Consider co-locating suction dependentpatients
Nursing staff BPaediatrict patientsneed to stay wherethere are paediatricnurses
Ensure adequate supply alternate drainagesystems
Nursing staff BLimited supply inhospital
Replace drain suction with manual vacuumor drainage bottles
Nursing staffMedical staff
BLimited supply inhospital
Page - 55 28/08/2013
CHILD & ADOLESCENT HEALTH UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITYHOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICE?
Provide emergencyoxygen/suction
Ensure small oxygen cylinder with twin-o-vac suction on resuscitation trolley
Nursing staff BLimited supply inhospital Only one inCAU.3x twin-o-vacs in CAU
Educate staff on use of alternate devices Unit Manager Educator
Digital scalesfail
Unable to record weight Use alternative scales Purchase bathroom scales Unit Manager C
Use weighted scales if available Unit Manager C
Failure ofWelsh Allenthermometer
Potential for inaccuracy oftemperature readings
Use digital thermometer Ensure stock digital thermometers Unit Manager C
Failure ofnon-invasivebloodpressure(NIBP)monitors
Unable to electronicallymeasure blood pressurerecordings
Use manual sphygmomanometer Ensure adequate number of manualsphygmomanometers
Unit Manager C
Failure ofGlucometer
Potential for decreasedaccuracy in blood glucosereadings
Change battery in Glucometer. Ensure adequate supply of batteries andtest strips.
Nursing staff /UnitManager
C
Inform and educate staff Unit Manager Educator C
Formal laboratory blood glucoseanalysis for abnormal results
Develop policy for formal laboratory test Medical staffNursing staff
A.A potential treatmentproblem.
Failure of 12lead ECGmachine
Unable to diagnosepotential life-threateningconditions
Ensure access to emergencypower
Identify access to emergency power outlet Unit ManagerEngineering staff
ANo problem ifemergency power pointkept for use.
Use on battery power Keep batteries fully charged on emergencypower
Unit Manager /NursingStaff
Alimited battery life
Page - 56 28/08/2013
CHILD & ADOLESCENT HEALTH UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITYHOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICE?
Identify location of alternative ECGmachines
Nursing staff
Inform and educate staff Unit Manager /Educator
Failure ofPulseoximeters
Unable to determineoxygen saturation
Increase nursing observation Educate staff re basic physical assessmentof patient
Educator CStaff trained in physicalassessment
Failure ofLamsonSystem
Unable to transportspecimens
Revert to manual process Inform and educate staff Unit Manager /Educator CCan function but verytime consuming
Failure ofEmergencyAlarms
Unable to provide safeand secure environment
Increased staff vigilance Schedule regular patient rounds Nursing staff BCan function but timeconsuming and canlead to decreasedpatient safety.
Direct notification via phone to switch orrunner to Communication Centre to contactfire services, security, police
All staff BCan function.
Refer to safety and security plan. Inform and educate Staff Unit Manager BCan function.
Failure ofPatient callbuttons
Patients unable tosummon assistance
Refer to safety and security plan. Inform and educate staff Unit Manager CCan function
Failure ofInfusionPumps/Syringe Drivers
Staff unable to titratemedications and fluidsaccurately
Use on battery power if available.
Charge on generator power if able Chargebatteries fully
All staff Nursing staff ABatteries can last up to12 hours.
Use burettes Ensure adequate stock burettes Nursing Staff AExtra staff will berequired.
Consider alternate administrationroutes.
Protocols for alternative administration Nursing staff Medical staff
Failure ofEnteral feedpumps
Difficulty in maintainingpatient nutrition
Use alternate enteral feedingmethods.
Develop procedure for bolus / gravityfeeding
Unit Manager/EducatorNursing Staff
CExtra staff required.
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CHILD & ADOLESCENT HEALTH UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITYHOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICE?
Ensure adequate supply tubes & bags &feeds
Unit Manager
Inform and educate staff Educator
Failure ofSequentialCompressionDevices
Potential increased risk ofDVT /Embolus
Use alternative methods ofdeterring thrombo-embolus
Identify at risk patients Unit Manager Medicalstaff
CNot common inpaediatrics
Consider compression stockings/ drugtherapy
Unit Manager /Educator/Medical Staff
CNot common inpaediatrics
Develop policy Unit Manager /Educator/Medical Staff
CNot common inpaediatrics
Ensure adequate supplies of stockings Nursing staff CNot common inpaediatrics
Refrigeration Drugs and medicalsupplies requiringrefrigeration may becomeunusable
Place drugs in refrigeratorswhich are connected toemergency power supply
Review emergency power outletsConsult with Pharmacy
Unit ManagerEngineering staffInfection Control staff
A
Monitor refrigerator temperature with thermometer
Nursing staff BAreas will need topurchase monitors.
Use Eskies and ice Consider purchase of eskies and supply ofice
Unit Manager Awith eskies.
Inform and educate staff Unit Manager Educator
Failure oflifting devices
Difficulties with liftingheavy patients – manualhandling injuries
Identify alternate lifting devices Use hydraulic lifting devices if available All staff B
Use of ski sheets, bed sheets, etc. All staff C
Ensure staff trained in manual handling Unit Manager Educator C
Page - 58 28/08/2013
CHILD & ADOLESCENT HEALTH UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITYHOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICE?
Pan roomhopper
Unable to clean bed pans/ urinals adequately
Single patient use bedpans/urinals
Purchase sufficient for immobile patients Unit Manager B
Rinse with “grey/waste” water and disinfect with chemical solution
All staff B
Inform staff of Infection Control policy Unit Manager Infection Control CNC Educator
Lift failure Unable to transportpatients to different levelswithin facility
Ensure one lift operates onemergency power
Review existing supply of emergency power Engineering staff Disaster Committee
Utilise alternate methods oftransporting patients
Walk patients Wards person
Consider scoop stretchers, fire blankets, stair walkers, cardboard stretchers
MHHS Executive ANeed increased staff.
Consider utilising ground floorfacilities
Develop facility plan for locating new admissions
MHHS Executive A
Minimise patient transfers Critical transfers only Medical staff A
Ensure all staff aware of facility Fire / Evacuation plan
Unit Manager A
Unit Manager Educator CCan still operate.
Failure ofVideo/TV
Negative impact onpatient educationenjoyment
Verbal education Develop alternate education packages forpatients
Medical Staff. CCan still operate.
Alternative recreational facilities Prepare mobile library Volunteers CCan still operate.
Page - 59 28/08/2013
CHILD & ADOLESCENT HEALTH UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITYHOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICE?
Consider hand held computer games forchildren
MHHS Executive UnitManager
C Can still operate.
Failure of Fax Unable to receive or sendpatient information
Utilise alternate lines ofcommunication
Send patient information by runner/courier Unit Manager ACan still operate buttime consuming.
Delay transfer of information until services resumed.
Medical staffAdmin. staff
ACan still operate buttime consuming.
Failure ofCopier
Unable to copydocuments
Utilise alternate lines ofcommunication
Telephone information Nursing staffMedical staff
CWill be very timeconsuming
Send original documents with patient anddocument in chart
Nursing staff Medical staff
CWill be very timeconsuming
Delay transfer of information until servicesresumed
Medical staffAdmin. staff
BStaffing Increased manual tasks
may influence workloadRoster extra staff on duty Estimate staffing numbers required for 24
hour periodAll managers
BPlace staff "on call" Prepare rosters All managers
BLiaise with agencies for extra staff All managers
CCall in staff Duty managers
BEquipmentFunction
Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon as possibleafter disruption of power
Identify all equipment to be checked Unit Manager All staff
B Inform and educate staff MHHS Executive
Unit Manager Educator
Page - 60 28/08/2013
Business Continuity Planning
Specialist Outpatients
SPECIALIST OUTPATIENTS
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Computer failure Unable to generate IDlabels
Unable to track patientlocation and bed status
Unable to accesscomputerisedpathology/radiologyresults
Record patient detailsmanually
Revert to manual process
Revert to manual process
Enter data when systemfixed
Ensure supply of HBCISdowntime forms
Pre –print labels on existingpatientsHand write on blank labelsfor new admissionsUpdate patient location andbed status at regularintervalsNotify after-hours managerof all patient movementsDevelop a process fordisseminating patientupdates as part of the facilitycommunication planEnsure supply of pathologyresult formsDevelop means fornotification of lab & testresultsManual ordering tests
Ensure retrospective dataentry when computerservices resumeBackup any non centraliseddata or ward specificcomputer programs
Administrative StaffNursing staff
Administrative staff
Unit ManagerLaboratory staff
Medical StaffNursing staffUnit ManagerLaboratory staff
Administrative staff
CCan function but very time
consumingInformation may not be
accurate
C
B
C
C
Power failure Mains power notavailable
Refer to mains powerfailure plan
Inform and educate staff Unit ManagerNurse Educator
Dunable to function due todarkness of area and
Page - 61 28/08/2013
SPECIALIST OUTPATIENTS
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
unavailability of Pathologyresults etc.
Lighting failure Difficulties in patientobservation and care.
Increased risk forpatients and staff
Utilise emergency lighting
Utilise alternate lighting
Maintain WH&Sprecautions
Refer to Facility wide powerfailure plan
Identify provision foremergency lightingRelocate immobile patientsto best lit areasClean and maintain windowsand fittingsEnsure blinds/curtains openEnsure adequate supplytorches / battery operatedlights and batteriesClear patient areas, workareas and corridors of allhazardsEducate staff
Engineering staff
Nursing staff
Cleaning staff
Unit Manager
Dunable to function due todarkness of area andunavailability of Pathologyresults etc.
CAir conditioning failure Unable to regulate
temperature andenvironment
Use alternate coolingdevices (eg.)
Electrical or manual fan
Refer to facility wide plan
Position fans for maximumbenefit and open doors andwindowsIdentify patients requiringcoolingInform and educate staff
Nursing staff
Unit Manager
C
Telephone failure No internal / externaltelephonecommunications .
Refer to facility widetelecommunications plan
Inform and educate staff Unit Manager
Wall oxygen supplyfailure.
Wall oxygen notavailable
Use cylinder oxygen Identify anticipatedrequirements of cylinderoxygen for ward patientsOrder required cylindersfrom central storage areaEnsure all oxygen cylindersfullEnsure correspondingnumber of oxygen fittingsavailable at ward level.Ensure all staff educated incylinder changeoverConsider co-locating high
Unit Manager
Wards person
C
C
Page - 62 28/08/2013
SPECIALIST OUTPATIENTS
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
oxygen users
Digital scales fail Unable to record weight Use alternative scales Purchase bathroom scalesUse weighted scales ifavailable
Unit Manager C
Failure of Welsh Allenthermometer
Potential for inaccuracyof temperature readings
Use digital thermometer Ensure stock mercurythermometers
Unit Manager C
Failure of non-invasiveblood pressure (NIBP)monitors
Unable to electronicallymeasure blood pressurerecordings
Use manualsphygmomanometer
Ensure adequate number ofmanualsphygmomanometers
Unit Manager C
Failure of Glucometer Potential for decreasedaccuracy in bloodglucose readings
battery change
Formal laboratory bloodglucose analysis forabnormal results
Ensure adequate stock ofblood glucose sticksInform and educate staffDevelop policy for formallaboratory test
Nursing staffUnit Manager
Medical staffNursing staff
C
Failure of 12 lead ECGmachine
Unable to diagnosepotential life-threateningconditions
Ensure access toemergency power
Use on battery power
Identify access toemergency power outlet
Keep batteries fully chargedon emergency powerIdentify location ofalternative ECG machines
Nursing staffUnit Manager
Brequired for medical
clinics
Failure of Pulse oximeters Unable to determineoxygen saturation
Use battery operatedoximeter.
Educate staff re basicphysical assessment ofpatient
Educator C
Failure of EmergencyAlarms
Unable to provide safeand secure environment
Increased staff vigilance
Refer to safety and securityplan.
Schedule regular patientroundsDirect notification via phoneto switch or runner toCommunication Centre tocontact fire services,security, police
Nursing staff
All staff C
Refrigeration Drugs and medicalsupplies requiringrefrigeration may
Place drugs in refrigeratorswhich are connected toemergency power supply
Review emergency poweroutlets
Unit ManagerEngineering staffInfection Control Staff
ADrugs kept in fridge
Page - 63 28/08/2013
SPECIALIST OUTPATIENTS
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
become unusable
Use Eskies and ice
Monitor refrigeratortemperature withthermometerConsider purchase of eskiesand supply of iceConsult with Pharmacy
Nursing staff
Failure of lifting devices Difficulties with liftingheavy patients – manualhandling injuries
Identify alternate liftingdevices
Use hydraulic lifting devicesif availableUse of ski sheets, bedsheets, etc.Ensure staff trained inmanual handling
All staff
Unit ManagerEducator
C
Pan room hopper Unable to clean bedpans / urinals adequately
Single patient use bedpans/urinals
Purchase sufficient forimmobile patientsRinse with “grey/waste”water and disinfect withchemical solutionInform staff of InfectionControl policy
Unit Manager C
Failure of Video/TV Negative impact onpatient education /enjoyment
Verbal education
Alternative recreationalfacilities
Develop alternate educationpackages for patients
Prepare mobile libraryConsider hand heldcomputer games for children
Unit ManagerEducator
Medical StaffVolunteers
c
Failure of Fax Unable to receive orsend patient information
Utilise alternate lines ofcommunication
Send patient information byrunner/courierDelay transfer of informationuntil services resumed.
Unit Manager
Medical staffAdministration staff
Anecessary for core
businessFailure of Copier Unable to copy
documentsUtilise alternate lines ofcommunication
Telephone information
Send original documentswith patient and document inchartDelay transfer of informationuntil services resumed
Nursing staffMedical staff
Anecessary for core
business
Staffing Increased manual tasksmay influence workload
Roster extra staff on duty
Place staff "on call"
Estimate staffing numbersrequired for 24 hour periodPrepare rosters
All managersB
no extra staff for area.
Page - 64 28/08/2013
SPECIALIST OUTPATIENTS
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Liaise with agencies forextra staffCall in staff Duty managers
Equipment Function Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon aspossible after disruption ofpower
Identify all equipment to bechecked
Inform and educate staff
Unit ManagerAll staffMHHS ExecutiveUnit Manager /Educator
Bnecessary for most clinics,
eg ECG's
Page - 65 28/08/2013
Business Continuity Planning
Renal Dialysis Unit
RENAL DIALYSIS UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITYHOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICE?
Most Haemodialysis patients can survive 3-4 days before the situation becomes life threatening. However with the volume of people on haemodialysis they all cannot bedialysed at once and one day without a means to dialyse patients will become critical for the group that has been dialysed 2-3 days prior.
Loss of Water Will result in inability todialyse patients.Severe medical impact onpatients
Delay dialysis until treated wateris available
Identify volume of water available & numberof patients able to e treated
Failure ofDialysisMachines
Will result in inability todialyse patients.Severe medical impact onpatients.Life threatening.
Delay Dialysis until machineavailable
Consider dialysis of all patients beforecritical periods.Check Urea & Electrolytes to establishclinical status
Failure ofElectricalPower
Will result in inability todialyse patients.Severe medical impact onpatients.Life threatening.
Equipment will not operatewithout electricity
Educate patient re alternativeshort term plans
Relocate patients to otherdialysis centres
Relocate patients to other Dialysis centres
Discuss options with the patientConsider dialysis of patients after hoursRoster staff to cover out of hours if requiredCall in staffCheck machinery function before attachingthe patientProvide dietary advice regarding fluidrestrictions and avoidance of high potassiumfood & beveragesLiaise with Infection Control re potential forcross infectionDiscuss options with patient
Ensure agreements exist for temporary
Unit ManagerMedical Director
Unit ManagerMedical Director
Unit ManagerMedical Director
Nursing StaffMHHS ExecutiveUnit ManagerMedical Director
Nursing Staff
Nurse Unit Manager
Nursing Staff
Nurse Unit ManagerMedical Director
Page - 66 28/08/2013
RENAL DIALYSIS UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITYHOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICE?
referral of patients to nearest dialysis centre
EquipmentFunction
Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon as possibleafter disruption of power/failureof machines
Identify all equipment to be checked
Inform and educate staff
Nurse Unit Manager
Nurse Unit Manager
Inability toContactDialysisPatients
Unable to discuss witheducate or managerelocation of patient fordialysis
Have radio contact phonenumbers of the Unit, ensure allpatients address and contactdetails are correct
Contact radio stations & utilise the police tocontact patients if needed
Nurse Unit ManagerMedical Director
Home PatientDialysis
Water or Power outage inthe community may resultin inability to operate themachine
Delay dialysis for 1-2 daysdependant on the patient needs
Educate the patient re potentialproblems
Hospital Dialysis
Discuss options with the patient
Provide dietary advice regarding fluidrestrictions and avoidance of high potassiumand beveragesIdentify High risk patientsAssess amount of battery time available andadvise patientsDevelop alternative treatment plans,including hospitalisation of conditiondeteriorates.
Nurse Unit Manager
Nursing Staff
Nursing Staff
HomePeritonealDialysis
Power outage incommunity may result inability to operate themachine
If peritoneal fluid available domanual PD exchanges
Educate patients re fluid andpotassium intakeHospital dialysis if poweravailable
Discuss options with the patient
Provide dietary advice
Identify high risk patients
Develop alternative treatment plansincluding hospitalisation if conditiondeteriorates
Nursing StaffCCan function but very time consuming
Page - 67 28/08/2013
Business Continuity Planning
Mental Health UnitNote: The Standard Operating Procedures for the general wards and the MHHS Essential Services are to be used in conjunction with the specific procedures detailed below.
MENTAL HEALTH UNIT
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you function
without this service?Loss of Power Decrease in service
delivery
No access tocomputerprograms/lab resultsfor patientsKeys – access tobuilding – will shutdown security accessto building
Refer to mains power failure planAccess to charts denied.Base some admin staff at MBHwith laptops and limit usage tochart search. Unit uses papercharts for everyday recording.Medical record charts can beaccessed manually from medicalrecords.UPS limited hours battery
Have keys available to staffmembers
Inform and educate staff
Admin staff to ensure batteriesof laptop charged duringwarning phase of disaster.
Ensure batteries are chargedand investigate possibility ofhaving portable generator torun some services.Ensure staff are available toassist with staff access to workunits
Team Leader
Business Manager andAdministration staff
Business Manager andAdministration staff
Business Manager
D
B
A
D
Loss ofCommunication
Staff/patient safety
Communication withstaff post event toassess availability for
Ensure staff safety on home visitsEnsure staff safety on ward
Staff contact list available. Policiesreflect staff protocols for returningto work post event.
Amend protocol for home visitsDevelop protocol for wardConsider staffing increase forstaff to work in pairs and/ oruse security servicesRationalise services considerdiverting all but seriously illpatients to community on atemporary basis. Increaseresources at Community todeal withInform patients and health careproviders/community servicesManager to keep staff recordsup to date.
Team LeaderCNCNurse Unit Manager
Nurse Unit Manager
Nurse Unit Manager
A
D
A
A
Page - 68 28/08/2013
MENTAL HEALTH UNIT
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you function
without this service?
work to provideservices or assistMHHS with recoveryStaff unable tocontact the centre orcommunicate withinthe centrePatients unable tocontact or becontacted
Ensure staff have mobile phonescharged and ready for use.
Use media to communicate currentsituation and advice.
Rationalise services. Chargemobile phones .Engagevolunteers or operational staffas runners.Manager to contact media
Business Manager B
A
B
ComputerFailure
Unable to generate IDlabels
Unable to enterCIMHA dataUnable to enterclinical incidentsDifficulty inadministration ofMental Health Actpaperwork/forms
Unable to trackpatients location andbed status
Inability to accesselectronic records -relevant client infounable to beaccessed.
Record patient details manually
Record information manually –draft extra admin staff to supportRecord information manually- draftextra admin staff to supportRecord information manually- draftextra admin staff to support
Revert to manual process
Access client record UR numberfrom MBH utilising mobile phone
Ensure supply of HBCISdowntime formsPre-print labels for existingpatientsHand write on blank labels fornew admissionsEnsure supply of CIMHAdowntime formsEnsure supply of PRIMEdowntime formsPossible extra support for theMHA Delegate to ensure allconsumers are correctlycategorised and that the legalduty for paperwork ismaintained.Update patient location andbed status at regular intervals
Notify after-hours manager ofall patient movementsDevelop a process fordisseminating patient updatesas part of the facilitycommunication planStaff education re procedure inevent of power/communication loss
Administrative and nursingstaff
MHA DelegateNUM
Administrative and nursingstaff
A
B
A
A
Page - 69 28/08/2013
MENTAL HEALTH UNIT
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you function
without this service?Availability andreadiness ofgovernmentcars
Inability to serviceclients in anemergency
Ensure all vehicles are fuelled upand garaged safely once warningsare issued
Allocate cars to program areasonce event is over
Business Manager A
Cars No fuel Decrease in servicedelivery to clients
Ensure that cars where practicalare adequately fuelled during anywarning phase.
All staff made aware of theneed to keep cars fuelled at alltimes.
Business Manager andteam Leaders
B
Failure ofDuress Alarmsystem
Increased risk to staffand other consumers
Keep only the most ill/high riskpatients and divert the rest tohome/community. Use extrasecurity and put resources tocommunity and or other wards tomanage outliers.
Identify emergency poweroutlets. Contacted theMaintenance Dept. They areconfident the system willcontinue to work.
All Nursing and Medicalstaff
DCANNOT OPERATE
SAFELY
Failure ofMonitorsincludingcardiac &oximetry
Unable to identifyarrhythmia’s / oxygensaturation. Low riskin the Mental HealthUnit
Utilise emergency generator powerwithin 10 seconds of power failure
Utilise battery back up
Locate functioning portablemonitorsIncreased nursing & medicalobservation
Identify emergency poweroutlets Have ECG machinecharged. Use manualSphygmomanometers. Pulseoximeter available which isbattery powered. Ensure allare charged and have sparebatteries availableEnsure batteries are fullychargedPrioritise patients formonitoringInform staff
All Nursing and Medicalstaff
All Nursing and Medicalstaff
Director of ICU and ICUConsultantsAll Nursing and Medicalstaff
A
ABattery life of Monitor is 30
mins to 2 hoursA
Insufficient staff Unable to providesafe level of care inthe event ofequipment failure
Use Unit base staffing model wherepossible.
Calculate individual patientstaffing requirementsIdentify critical care staff ableto be on call and redeployed inthe facilityEstimate staffing numbersrequired for 24 hour periodLiaise with other facilities forextra critical care staffLiaise with agencies for extracritical care staffCall staff in when required
NUMTeam Leader
Indefinitely but with a limitedservice
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Business Continuity Planning
Community Mental HealthNote: The Standard Operating Procedures for the general wards and the MHHS Essential Services are to be used in conjunction with the specific procedures detailed below.
COMMUNITY MENTAL HEALTH
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you
function without thisservice?
Loss of Power Decrease in servicedelivery
No access tocomputer programs
Keys – access tobuilding – will shutdown security accessto building
Refer to mains powerfailure planAccess to charts denied.Base some admin staff atMBH with laptops and limitusage to chart search.UPS limited hours battery
Have keys available tostaff members
Inform and educate staff
Admin staff to ensurebatteries of laptop chargedduring warning phase ofdisaster.Ensure batteries arecharged and investigatepossibility of having portablegenerator to run someservices.Ensure staff are available toassist with staff access towork units
Team Leader
Business Manager and Admin staff
Loss ofCommunication
Staff/patient safety
Communication withstaff post event toassess availability forwork to provideservices or assistMHHS with recoveryStaff unable tocontact the centre orcommunicate within
Ensure staff safety onhome visits
Staff contact list available.Policies reflect staffprotocols for returning towork post event
Ensure staff have mobilephones charged andready for use.
Amend protocol for homevisitsConsider staffing increasefor staff to work in pairsRationalise servicesInform patients and healthcare providers/communityservicesManager to keep staffrecords up to date.
Rationalise services. Chargemobile phones .Engagevolunteers or operational
Team Leader
Service Integration Coordinator
Business Manager
Business Manager
Page - 71 28/08/2013
COMMUNITY MENTAL HEALTH
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you
function without thisservice?
the centrePatients unable tocontact or becontacted
Use media tocommunicate currentsituation and advice
staff as runners.Manager to contact media
ComputerFailure
Unable to generate IDlabels
Unable to enterCIMHA dataUnable to enterclinical incidentsInability to accesselectronic records -relevant client infounable to beaccessed.
Record patient detailsmanually
Record informationmanually
Access client record URnumber from MBH utilisingmobile phone.
Ensure supply of HBCISdowntime formsPre-print labels for existingpatientsHand write on blank labelsfor new admissionsEnsure supply of CIMHAdowntime formsEnsure supply of PRIMEdowntime formsStaff education re procedurein event of power/communication loss
Develop a process fordisseminating patientupdates as part of the facilitycommunication plan
Administrative and nursing staff
Availability andreadiness ofgovernmentcars
Inability to serviceclients in anemergency
Ensure all vehicles arefuelled up and garagedsafely once warnings areissued
Allocate cars to programareas once event is over
Business Manager
Cars No fuel Decrease in servicedelivery to clients
Ensure that cars wherepractical are adequatelyfuelled during any warningphase.
All staff made aware of theneed to keep cars fuelled atall times.
Business Manager and team Leaders
Insufficient staff Unable to providesafe level of care inthe event ofequipment failure
Use Unit base staffingmodel where possible.
Calculate individual patientstaffing requirements
Identify critical care staffable to be on call andredeployed in the facilityEstimate staffing numbers
NUM and Team Leader
NUM and Team Leader
Indefinitely but with alimited service
Page - 72 28/08/2013
COMMUNITY MENTAL HEALTH
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you
function without thisservice?
required for 24 hour periodLiaise with other facilities forextra critical care staffLiaise with agencies forextra critical care staffCall staff in when required
Page - 73 28/08/2013
Business Continuity Planning
Alcohol Tobacco & Other Drugs ServiceNote: The Standard Operating Procedures for the general wards and the MHHS Essential Services are to be used in conjunction with the specific procedures detailed below.
A.T.O.D.S
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you function
without this service?Loss of Power Decrease in service
delivery
No access tocomputer programs
Keys – access tobuilding – will shutdown security accessto building
Refer to mains powerfailure planAccess to charts denied.Base some admin staff atMBH with laptops and limitusage to chart search.UPS limited hours battery
Have keys available tostaff members
Inform and educate staff
Admin staff to ensurebatteries of laptop chargedduring warning phase ofdisaster.Ensure batteries arecharged and investigatepossibility of having portablegenerator to run someservices.Ensure staff are available toassist with staff access towork units
Team Leader
Business Manager and Admin staff
Loss ofCommunication
Staff/patient safety
Communication withstaff post event toassess availability forwork to provideservices or assistMHHS with recoveryStaff unable tocontact the centre orcommunicate withinthe centre
Ensure staff safety onhome visits
Staff contact list available.Policies reflect staffprotocols for returning towork post event.
Ensure staff have mobilephones charged andready for use.
Amend protocol for homevisitsConsider staffing increasefor staff to work in pairsRationalise servicesInform patients and healthcare providers/communityservicesManager to keep staffrecords up to date.
Rationalise services. Chargemobile phones .Engagevolunteers or operationalstaff as runners.
Team Leader
Service Integration Coordinator
Business Manager
Business Manager
Page - 74 28/08/2013
A.T.O.D.S
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you function
without this service?Patients unable tocontact or becontacted
Use media tocommunicate currentsituation and advice
Manager to contact media
ComputerFailure
Unable to generate IDlabels
Unable to enterCIMHA dataUnable to enterclinical incidentsInability to accesselectronic records -relevant client infounable to beaccessed.
Record patient detailsmanually
Record informationmanuallyAccess client record URnumber from MBH utilisingmobile phone.
Ensure supply of HBCISdowntime formsPre-print labels for existingpatientsHand write on blank labelsfor new admissionsEnsure supply of CIMHAdowntime formsEnsure supply of PRIMEdowntime formsStaff education re procedurein event of power/communication lossDevelop a process fordisseminating patientupdates as part of the facilitycommunication plan
Administrative and nursing staff
Availability andreadiness ofgovernmentcars
Inability to serviceclients in anemergency
Ensure all vehicles arefuelled up and garagedsafely once warnings areissued
Allocate cars to programareas once event is over
Business Manager
Cars No fuel Decrease in servicedelivery to clients
Ensure that cars wherepractical are adequatelyfuelled during any warningphase.
All staff made aware of theneed to keep cars fuelled atall times.
Business Manager and team Leaders
Page - 75 28/08/2013
Business Continuity Planning
Early DischargeGeneral EDSU Contingencies:This Continuity Plan is based on having Emergency Power to the Unit. If there is no power all procedures would cease and cases would have to betransferred
EARLY DISCHARGE SURGERY UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUTTHIS SERVICE?
Failure ofanaestheticmachines &ventilators
Loss of power to machine
Inaccurate delivery ofanaesthetic gases
Unable to ventilatepatients
Run on emergency generatorpower . Runon gases if no power Oxygendriven) for 90 minutes only.Use backup cylinder supplies ofoxygen, nitrous oxide & airHand ventilate
Check access to emergency poweroutlets.Manually ventilate.Manually physically assess
Ensure supplies of cylinder gassesavailable
Ensure adequate supply of handoperated ventilation equipment - blackbag, bag - valve device
Locate and provide air / oxygen drivenventilator (oxylog / birds)
Cancel elective surgery
Unit ManagerAnaesthetic staff
Unit ManagerWards person
Unit ManagerAnaesthetic staff
Unit ManagerAnaesthetic staff
Director of AnaestheticsDirector of SurgeryNurse Unit Manager
ESC & DMS/DON/ND
D
Failure ofMonitors –cardiac oximetry,end tidal CO2
Unable to identifyarrhythmias / oxygensaturation and problemswith ventilation
Run on emergency generatorpower
Check access to emergency poweroutlets
Identify & ensure adequate medical &nursing staff coverage
Unit ManagerAnaesthetic Staff
Director of AnaestheticsCNC
D
Defibrillator doesnot function
Unable to defibrillatepatients
Use on emergency generatorpower or battery power.Use battery back up if available
Check access to emergency poweroutlets
Have batteries fully charged
Unit Manager
All staff
D
Page - 76 28/08/2013
EARLY DISCHARGE SURGERY UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUTTHIS SERVICE?
Failure ofEndoscopicEquipment
Unable to performendoscopic procedures(may be done ifgenerator on emergencypower)
Use on emergency generatorpower or battery power.
Postpone all non urgent surgery
Notify surgeons, medical, nursing andbooking office
Contact non urgent patients and informre need to reschedule at later date
Ensure list of procedures unable to beunder taken available at theatre frontdesk
Unit Manager
BookingsTheatre Manager
Unit ManagerMedical Staff
D
Failure ofdiathermymachine
Unable to performelectrical coagulation(may be done if generatoron emergency power).
Use on emergency generatorpower or battery power.
Notify surgeons, medical, nursing andbooking office
Unit Manager
Failure ofFibredryer(NOT ONEMERGENCYPOWER).
Unable to store processedscopes
Arrange for use on emergencypower
Notify surgeons, medical, nursing andbooking office D
Failure ofSterilisingequipment forscopes (ONEMERGENCYPOWER)
Unable to steriliseendoscopic equipment
Arrange for use on emergencypower
Notify surgeons, medical, nursing andbooking office
Identify suitable patients
Contact non urgent patients and informre need to reschedule at later date
Staff education – availability of types ofcases able to be done
List of procedures unable to be undertaken available at theatre desk
Medical staff
Unit ManagerEngineering staff
Unit Manager
Unit ManagerMedical staff
D
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EARLY DISCHARGE SURGERY UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUTTHIS SERVICE?
ContaminatedWater supply ordamage to waterfilters
Unable to perform/cleanand sterilise proceduresand equipment accordingto Australian Standards
Arrange for supply of sterilewater
Rationalise service to emergencyuse only
Ensure large supply of water availablebefore restarting procedures
Identify and prioritise critical services
Unit ManagerMedical staff
MHHS ExecutiveUnit Manager
D
Failure of lift Unable to transport patientto/from DPU
Ensure one lift operates onemergency power
Review existing supply of emergencypower
Consider locating all surgical patientson same level as Surgical Services
Manager Engineering
MHHS ExecutiveDirector of Surgery
C
Staffing Unable to provide safelevel of care in the eventof equipment failure
No available Staff toprovide care
Increased manual tasksmay influence workload
Centralise surgical services atone site in MHHS over criticalperiods
Roster additional staff
Disaster Plan has all availablephone numbers up to date.Roster extra staff on dutyPlace staff "on call"
Develop a staffing plan for MHHS.
Calculate individual unit staffingrequirements
Identify need to maintain staff on site asopposed to on call.
Identify human resources able to be oncall and redeployed in the facility
Assess competence of on call staff
NUM to ensure Disaster Plan is current
Estimate staffing numbers required for24 hour periodPrepare rostersLiaise with agencies for extra staffCall in staff
Unit ManagerDirector of Surgery
Unit ManagerDirector of Surgery
Unit ManagerDirector of Surgery
Unit ManagerNurse manager
Unit Manager
NUM
All Managers
All ManagersAll ManagersDuty Managers
C
Page - 78 28/08/2013
EARLY DISCHARGE SURGERY UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUTTHIS SERVICE?
EquipmentFunction
Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon as possibleafter disruption of power
Identify all equipment to be checked
Inform and educate staff
Unit ManagerAll staff
MHHS ExecutiveUnit Manager
A
No lights inchange rooms
Staff may not feel safe. Torches are available in the unit.Security to inspect all areasbefore staff enter.
Ensure batteries are in unit. Arrangesecurity inspection.
NUMA
Computer failure Unable to generatemaitain data base, printpatient ID & paperwork
Unable to track patientlocation and bed status
Unable to provide patientdietary requirements
Unable to recordinformation relating topatient nurse dependency
Unable to accesscomputerisedpathology/radiologyresults
Record patient details manually
Revert to manual process
Revert to manual process
Revert to manual process
Revert to manual process
Ensure supply of HBCIS downtimeforms
Pre –print labels on existing patients
Hand write on blank labels for newadmissions
Update patient location and bed statusat regular intervals
Notify after-hours manager of all patientmovements
Develop a process for disseminatingpatient updates as part of the facilitycommunication plan
Update patient diet lists and haveavailable for collection by cateringservices
Ensure supply of downtime formsavailable to record information
Ensure supply of pathology result forms
Administrative and nursingstaff
Administrative and nursingstaffAdministrative and nursingstaff
Administrative and nursingstaff
Nursing staff
Nursing Staff TeamLeader
Unit Manager
Administrative staff
Administrative staff
Unit Manager & Lab staff
C
C
C
C
Page - 79 28/08/2013
EARLY DISCHARGE SURGERY UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUTTHIS SERVICE?
Enter data when system fixed
Develop means for notification of lab &test results
Manual ordering tests
Ensure retrospective data entry whencomputer services resume
Backup any non centralised data orward specific computer programs
Medical & nursing staff
Unit Manager & Lab staff
Administrative staff C
Power failure Mains power not available Refer to mains power failure plan Inform and educate staff Unit Manager /NurseEducator
D
Lighting failure Difficulties in patientobservation and care.
Increased risk for patientsand staff
Utilise emergency lighting .Torches in all areas.
Maximise natural lighting
Utilise alternate lighting
Maintain WH&S precautions
Refer to Facility wide powerfailure plan
Identify provision for emergency lighting
Relocate immobile patients to best litareas
Clean and maintain windows andfittings
Ensure blinds/curtains open
Ensure adequate supply torches /battery operated lights and batteries
Clear patient areas, work areas andcorridors of all hazards
Educate staff
Engineering staffNUMNursing staff
Cleaning staff
All staff
Unit Manager
Unit Manager /All staff
Educator
C
C
Air conditioningfailure
Unable to regulatetemperature andenvironmentUnable to perform surgerydue to risk of infectionPossible loss of sterile
Open Windows where possible.
Electrical or manual fan
Refer to facility wide plan
Position fans for maximum benefit
Identify patients requiring coolingInform and educate staffInform and educate staff
Nursing staff
Nursing staffUnit ManagerShift Team Leader
C
Page - 80 28/08/2013
EARLY DISCHARGE SURGERY UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUTTHIS SERVICE?
stock due to high temps. Educator
Telephone failure No internal / externaltelephonecommunications .
Refer to facility widetelecommunications plan
Inform and educate staff Unit ManagerA
Wall oxygensupply failure.
Wall oxygen not available Use cylinder oxygen Order required cylinders from centralstorage area.
Ensure all oxygen cylinders full
Ensure corresponding number ofoxygen fittings available at ward level.
Ensure all staff educated in cylinderchangeover.
Consider co-locating high oxygen users
Wards person
Wards person
Wards person
Wards personUnit ManagerEducatorNursing staffmedical Staff
C
Wall suctionfailure
Wall suction not available Use alternate suction devices
Provide emergencyoxygen/suction
Assess need for and number of portablesuction units required as there is notone within the department.There is one located in theatres
Consider co-locating suction dependentpatients
Ensure adequate supply alternatedrainage systems
Replace drain suction with manualvacuum or drainage bottles
Ensure small oxygen cylinder with twin-o-vac suction on resuscitation trolley
Educate staff on use of alternatedevices
Unit Manager
Nursing staff
Nursing staff
Nursing staffMedical staff
Nursing staff
Unit ManagerEducator
D
Page - 81 28/08/2013
EARLY DISCHARGE SURGERY UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUTTHIS SERVICE?
Failure of WelchAllen monitors
Unable to electronicallymeasure pt observations
Use manual sphygmomanometer
Use on emergency generatorpower or battery power.
Ensure adequate number of manualsphygmomanometers
Check access to emergency poweroutlets
Unit Manager
Unit Manager
D
Failure of 12 leadECG machine
Unable to diagnosepotential life-threateningconditions
Ensure access to emergencypower
Use on battery power
Identify access to emergency poweroutlet
Keep batteries fully charged onemergency power
Identify location of alternative ECGmachines
Inform and educate staff
Unit ManagerEngineering staff
Unit ManagerNursing Staff
Nursing staff
Unit ManagerEducator
D
Failure of LamsonSystem
Unable to transportspecimens
Revert to manual process Inform and educate staff Unit ManagerEducator D
Failure ofEmergencyAlarms
Unable to provide safeand secure environment
Increased staff vigilance
Refer to safety and security plan.
Schedule regular patient rounds
Direct notification via phone to switch orrunner to Communication Centre tocontact fire services, security, police
Inform and educate Staff
Nursing staff
All staff
Unit Manager
D
Failure of Patientcall buttons
Patients unable tosummon assistance
Refer to safety and security plan. Inform and educate staff Unit ManagerD
Failure of InfusionPumps/SyringeDrivers
Staff unable to titratemedications and fluidsaccurately
Use on battery power if available
Use burettes
Consider alternate administrationroutes.
Charge on generator power if ableCharge batteries fully
Ensure adequate stock burettes
Protocols for alternative administration
All staffNursing staff
Nursing StaffNursing staffMedical staff
D
Page - 82 28/08/2013
EARLY DISCHARGE SURGERY UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUTTHIS SERVICE?
Refrigeration(Connected toEmergencypower). Alert staffif no emergencypower to makeplans forrefrigerateddrugs.
Drugs and medicalsupplies requiringrefrigeration may becomeunusable
Place drugs in refrigeratorswhich are connected toemergency power supply
Use Eskies and ice
Review emergency power outlets
Monitor refrigerator temperature withthermometer
Consider purchase of eskies and supplyof iceInform and educate staffConsult with Pharmacy
Unit ManagerEngineering staff
Nursing staff
Unit ManagerInfection Control Staff
Unit ManagerEducator
D
Pan roommacerator
Unable to dispose of bedpans / urinals adequately
Single patient use bedpans/urinals
Purchase sufficient for immobilepatients
Rinse with “grey/waste” water anddisinfect with chemical solution
Inform staff of Infection Control policy
Unit Manager
All staff
Unit ManagerInfection Control CNCEducator
A
Lift failure Unable to transportpatients to different levelswithin facility
Ensure one lift operates onemergency power
Utilise alternate methods oftransporting patients
Consider utilising ground floorfacilities
Minimise patient transfers
Review existing supply of emergencypower
Walk patients
Consider scoop stretchers, fireblankets, stair walkers, cardboardstretchersDevelop facility plan for locating newadmissions
Critical transfers only
Ensure all staff aware of facility Fire /Evacuation plan
Engineering staffDisaster Committee
Wards person
MHHS Executive
MHHS Executive
Medical staff
Unit Manager
D
Page - 83 28/08/2013
EARLY DISCHARGE SURGERY UNITA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUTTHIS SERVICE?
Failure of Fax Unable to receive or sendpatient information
Utilise alternate lines ofcommunication
Send patient information byrunner/courier
Delay transfer of information untilservices resumed.
Unit Manager
Medical staffAdmin. staff
D
Failure of Copier Unable to copydocuments
Utilise alternate lines ofcommunication
Telephone information
Send original documents with patientand document in chart
Delay transfer of information untilservices resumed
Nursing staffMedical staff
Nursing staffMedical staff
Nursing staffMedical staff
D
Page - 84 28/08/2013
Business Continuity Planning
Mackay Breastscreen
MACKAY BREASTSCREENA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICELoss of Power Complete loss of
service deliveryAdvise public of servicecommunication problems throughthe media
Inform & Educate staff ManagerD
Loss ofCommunication
Unable to communicatewith clients to bookappointments
Advise the Public of servicecommunication problems throughthe Media
Administration staff to make clientappointments in person
ManagerD
EquipmentFailure
Failure ofMammographyUltrasound machinewould unable service toperform core businessof screening andassessment.Failure of IT equipmentwould unable service touse State wide database to access clientrecords
Service has 2 MammographyMachines and can continue toscreen with 1 machine down. IfUltrasound machine failed clientswould be booked for nextassessment clinic. If data basefailed bookings and data entrycan be entered at a later time.
If problem occurred at the time of taking amammogram radiographer is able tomanually release client from compression.BETS would be contacted to fix equipment.Client requiring ultrasound would berebooked when machine operational.Client info can be entered into data base ata later time
RadiographerData ManagerService Manager
A
Page - 85 28/08/2013
Business Continuity Planning
CSSDBased on emergency generator functioning. No emergency power to CSSD, lighting only No air-conditioning to CSSD when on generator.
CSSD DEPARTMENT
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility
Failure of steamsteriliser. UseSterrad steriliseronly.
Unable to processtheatre/ward linen bundles.
Use disposable linen for allprocedures. Transport Sterrad totheatre to emergency power
Equipment nurse to facilitatepurchase costingsimplementation of disposablelinen.
NUMMHHS Executive.
Nowasher/disinfectorconnected toemergency power.
Unable to processreusable medicalequipment/instruments.
Manually wash all equipment. Explore the possibility ofconnecting of one machine toemergency power.
NUMEngineer
No dryersconnected toemergency power.
Difficulty drying adequatequantities of equipment toSterrad sterilisers.
Manually dry all equipment. Explore the possibility ofconnecting of one machine toemergency power.
NUMEngineer
Ward instrumentshortage.
Ward/A&E/ICU/shortage ofsterile instruments.
Purchase pre-prepared instruments Equipment nurse to facilitatepurchase/costings/implementation/ofinstrument packs.
Unit Manager
No red emergencypower points in thedepartment.
Unable to use anyequipment
Take equipment to theatre to use. Explore the possibility ofconnecting emergency power.
NUMEngineer
Failure of steriliser Unable to process wardand theatre instrumentsUnable to provide dentalservices
Ensure one steriliser on emergencypowerAlternative sterilisation methods
Rationalise service to emergency useonly
Identify emergency power supplyto sterilisersInvestigate alternativesterilisation methods eg ,chemical sterilisationEnsure full stock levels of sterileequipment available prior tocritical periodsIdentify and prioritise criticalservices
Unit ManagerEngineering staff
Unit Manager
MHHS ExecutiveUnit Manager
Failure ofinstrument / tubewasher
Unable to cleaninstruments / tubes
Utilise disposable consumables usemanual methodRevert to manual process
Ensure stock at maximum levels
Manually wash instruments &tubes
Manager
Nursing staff
Page - 86 28/08/2013
CSSD DEPARTMENTA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility
Unable to disinfectanaesthetic ventilationtubing
Utilise disposable consumables Ensure stock at maximum levels Unit Manager
Failure ofinstrument / tubedryers
Unable to dry instrumentsand tubing effectively
Alternative strategies for drying
Sterilise instruments just in time foruse
Manually dry instruments & tubes
Air dry
Set up trays for immediate useand ‘flash sterilise’ as required
Nursing staff
Nursing staff
Nursing staff
Ward instrumentshortage
Shortage of sterileinstruments available towards
Have all available instrumentsprepacked in peel packs
Use disposable instruments andpacks
Purchase any additionalequipment if required
Purchase disposablesIdentify storage area for extrapacksNotify wards/units of contingency
MHHS ExecutiveUnit Manager
Failure of sterilisedlinen service
No Sterile Linen bundles Have maximum stores available
Rationalise use of linenAlternative supplierUse disposable linen
Prepacked and ensure maximumstore of sterile linenDevelop a plan for rationingConsider alternative supplierOrder extra supplies ofdisposable linen
Unit Manager
Equipment function Unable to guaranteeequipment accuracy
Check all equipment for functionalityas soon as possible after disruption ofpower/failure of machines
Identify all equipment to bechecked
Inform and educate staffUnit Manager
Page - 87 28/08/2013
Business Continuity Plan
Health Information Division
HEALTH INFORMATION UNIT
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Failure HBCIS Medical Records& Request Tracking System
Unable to locate & sendmedical records
Ensure all records in fileprior to critical dates -presumes there is advancenoticeRun location by location forcharts not returned -providing power sufficient torun HBCISRevert to manualcommunication systems forrequesting medical recordsUse manual tracing system
Notify all MO’s/wards/deptsto return outstanding records(Antenatal excluded)
Manager to arrangeappropriate staff to completetask.
Notify hospital departmentsabout manual system
�Implement manual system
� (eg) tracer cards
Update system with changes& new registrations
Manager / Supervisor
HBCIS Data Manager
Manager / Supervisor
Manager / Supervisor
Administrative staff & WardClerks
Depends on the severity ofthe disaster
Manual allocation of URN’s Check backup PMI file is upto date - may not besufficient notification to dothis
Use backup PMI to look upexisting URN’s - may not besufficient notification to dothis
Manually allocate & look upURN’sUpdate system when systemback online
Print hard copy of PMI priorto critical date - may not besufficient notification to dothis
Failure of HBCIS Patient MasterIndex (PMI)
Cannot allocate new URNumbers
Cannot search forexisting URN’s
Manual process
Use the block of unissueddowntime UR numbers
Allocate downtime URnumbers
HBCIS Data Manager
Administrative staff
HBCIS Data Manager
Administrative staff
Depends on the severity ofthe disaster
Failure HBCIS Admission,Transfer, Discharge (ADT)
Cannot search ADT totrack patients
Not critical, wait untilsystem returns
Update System Administrative staff & WardClerks
C:Weeks – Indefinitely
Page - 88 28/08/2013
HEALTH INFORMATION UNIT
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Cannot run enquiryreports
Keep hard copy list inMedical RecordsDepartment - may not besufficient notification to dothis
Have register and down timeforms available. Updatepatient list as needed
Administrative staff
Update system when systemback online
Failure of Coding System Unable to enter codes
Unable to access reports
Copy codes to front sheetand use manual tally sheet(label & codes)Access when systemreturns
Update system when systemback on line
Clinical Coders
Clinical Coders
C:Weeks – Indefinitely
Equipment function H machine not working
Dumb Waiter notworking
Use manual record requestsystem
Revert to physical chartdelivered to EmergencyDepartment
Check all equipment forfunctionality as soon aspossible after disruption ofpower/failure of machinery
Supervisor/Administrative staff C:Weeks – Indefinitely
HBCIS Appointment Scheduling Unable to print reportsfor patients attendingclinics
Print reports one week inadvance where possible(Laptop)
Manual list of attendees HBCIS Data Manager
No access to activity data Unable to access reports Access when ssytemreturns
Retrospective updating ofdata
Decision Support Coordinator C:Weeks – Indefinitely
Unable to fax dischargesummaries
Unable to respond torequests from GP's forfollow up dischargeinformation
Hand write dischargesummaries. Give patients acopy on discharge
Post copy handwrittendischarge summaries toGeneral Practitioners
ROI OfficerC:
Weeks – Indefinitely
Flooding of Medical recordDepartment
Destruction of charts If possible move charts tosafe area
Arrange for staffing to movecharts
Manager C:Weeks – Indefinitely
Flooding/destruction of InactiveRecords Shed
Destruction of charts If possible move charts tosafe areaPrioritise charts to save
Arrange for staffing to movecharts
Manager C:Weeks – Indefinitely
Page - 89 28/08/2013
Business Continuity Planning
Corporate Support Services –Travel Office
TRAVEL OFFICEA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOUFUNCTION WITHOUT
THIS SERVICELoss of Power Complete loss of
service deliveryUnable to book travel PSA clients advising of situation
Contact main referral hospitals to adviseManager
D
Loss of Phones Unable to communicatewith clients to booktravel
PSA to advise clients to present inperson
Business as usual if clients present ManagerB
EquipmentFailureTravel ManagerMFD
Complete loss ofservice delivery
Delay to processingtravel
Manual data input with data to beput in later
Use MFD in another Department,need fax re-diverted
Urgent travel only able to be booked
Business as usual
Manager D
B
Page - 90 28/08/2013
Business Continuity Planning
Information Division
INFORMATION DIVISION
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you function
without this service?
Failure of primarydatacommunications toData Centre
No impact to applicationaccess, communicationsautomatically switches tobackup data communicationservice
Automatic switch over to Optusbackup link.
Switch over backupautomatic
ID Team leader
Failure of all datacommunications toData Centre
Loss of corporately hostedEnterprise Applications: egAuslab, EDIS, FAMMIS,internet, iPharmacy, QHEPS.Access to Groupwise andHBCIS unaffected
Escalate issue with EnterpriseOperation Centre
Liaise with EOC todetermine possiblealternate connectionoptions
ID Team leader
Failure ofEnterprise DataCentre
Loss of corporately hostedEnterprise Applications: egAuslab, EDIS, FAMMIS,internet, iPharmacy, QHEPS.Access to Groupwise andHBCIS unaffected
Pathology and Finance systemsdown – Departments revert tomanual system no availablecontingency.
Determine minimal levelof function
MHHS ExecutiveID Team leader
Failure ofHBCIS primaryserver
No access to HBCIS Revert to HBCIS standby server Switch over to standbyserverRestore normaloperation of HBCISPrimary server
ID Team Leader
SIM1/ID Team Leader
Failure ofHBCISapplication
No access to HBCIS Medical Records use backupPMI
Revert to HBCISPrimary ServerMedical Records revertto manual look upsystem.Medical Records revertto manual look upsystem.Restore operation ofHBCIS application
SIM1/ID Team Leader
Health Information Manager
SIM1/ID Team Leader
Page - 91 28/08/2013
INFORMATION DIVISION
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can you function
without this service?
Switch to manual businessprocesses if required
Inform business units ofissues and timeframes
Failure ofMackay BaseHospital FileServer
No access to G:/H: drives,network printing, server basedlocal applications eg RIPS
Restore server operation
Switch to manual businessprocesses if required
If hardware failureinitiate vendor support -Investigate availablehardware replacementoptions as requiredIf software failure - Techops Directories/Novellfor assistanceIf required restore datafrom backupInform business units ofissues and timeframes
ID Team Leader/Businessunits
Failure ofMackay BaseHospitalGroupwiseServer
No access to Groupwise Restore server operation
Switch to manual businessprocesses if required
If hardware failureinitiate vendor support -Investigate availablehardware replacementoptions as requiredIf software failure - Techops Directories/Novellfor assistanceIf required restore datafrom backupInform business units ofissues and timeframes
ID Team LeaderTechnical OperationsSupport vendor
INFORMATION DIVISION – DESKTOP SERVICES
Failure of LocalArea Network
Loss of access toEnterpise/Local applications
Restore network operation
Switch to manual businessprocesses if required
If possible reconfigurenetwork to re-establishoperationInform business units ofissues and timeframes
ID Team LeaderEnterpirse Operation Centre
ID Team LeaderBusiness units
Page - 92 28/08/2013
Business Continuity Planning
Medical ImagingSome areas within Medical Imaging are connected to the emergency generator
MEDICAL IMAGINGA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
Problem Impact Contingency Task Responsibility How long can you function without this service?
Loss of Power No CT Service.
Use alternateinvestigation ifpossible.Outsource tolocal privatepractices.
CT is ongenerator powerwill function aslong asgenerator isoperational.
Director of Medical Imaging, radiographers and Engineering staff. Up to 24hrs, maybe extendedin consultation with local private practices ability to provide alternate service
No X-RayService.
Key equipmenton UPS.EmergencyPower.Mobile x-rayunits.
Test andmaintain UPS.AssessEmergencypower for x-ray
Director of Medical Imaging, radiographers, Engineering staff and BTS staff.Indefinitely with reduced capacity as long as generators are operational.
No UltrasoundService.
Equipment onemergencypower. Usealternate test
Test andmaintain UPS.AssessEmergencyPower forUltrasound
Director of Medical Imaging, sonographers and Engineering staff.Indefinitely with reduced capacity as long as generators are operational.
Key Equipmentfailure.
No CT Service. Use alternateinvestigation ifpossible.Outsource tolocal privatepractices.
Ensureequipment ismaintained ingood workingorder throughregularscheduledservicing.
Director of Medical Imaging, radiographers and servicing agent.Up to 24hrs, maybe extended in consultation with local private practices ability to providealternate service
No X-RayService.
Use alternateunit.Mobile x-ray
Ensureequipment is
Director of Medical Imaging, radiographers and BTS Director.Indefinitely with reduced capacity as long as other like equipment remains operational.
Page - 93 28/08/2013
MEDICAL IMAGINGA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
Problem Impact Contingency Task Responsibility How long can you function without this service?
units. maintained ingood workingorder throughregularscheduledservicing.
No UltrasoundService.
Use alternateinvestigation ifpossible.Use alternativeU/S unit.Outsource tolocal privatepractices.
Ensureequipment ismaintained ingood workingorder throughregularscheduledservicing.
Director of Medical Imaging, sonographers and servicing agent.Indefinitely with reduced capacity as long as other like equipment remains operational.
MedicalImagingenvironmentunsafe
Service cannotbe provided inMedical Imaging.
Relocateultrasound units.Relocate mobilex-ray units.Relocate CoreCR Equipment.
Alternate site tobe identified.Mobile shieldinginstalled.Necessaryconsumablesrelocated.Emergencynetwork to beestablished. CToutsourced toLocal PrivatePractice.
Director of Medical Imaging, Medical Imaging staff, BTS staff, Information Division staff andEngineering staff.Up to 5 days with reduced service reflective of the capacity of alternate site
No CT Service.
Use alternateinvestigation.Outsource tolocal privatepractices.
Outsource toLocal PrivatePractice. Noonsitealternative.
Director of Medical Imaging and Medical Imaging staff.Up to 24hrs, maybe extended in consultation with local private practices ability to provide theservice
Page - 94 28/08/2013
MEDICAL IMAGINGA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
Problem Impact Contingency Task Responsibility How long can you function without this service?
Insufficientstaff
Unable toprovide sufficientand safe level ofservice.
Recall of allavailable staff asrequired.
Calculateindividual staffingrequirements.
Director ofMedical ImagingorOn callRadiographer.
Indefinitely but with a limited service.
Estimate staffingnumbersrequired for 24hour period.
Director ofMedical Imaging
Indefinitely but with a limited service.
Liaise with otherHHSs/CASS forextra staff.
Director ofMedical Imaging
Indefinitely but with a limited service.
Liaise with locumagencies forextra staff.
Director ofMedical Imaging
Indefinitely but with a limited service.
Page - 95 28/08/2013
Business Continuity Plan
Pathology Services.
PATHOLOGY SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can youfunction without thisservice?
Failure of PowerSupply
Laboratory unable tofunction without power
Ensure access toemergency power
Use alternate testing facilityoutside organisation
Use of the iSTAT for urgenttests
Confirm availability of emergencypowerEnsure all critical equipmentsupplied with emergency powerRationalise all services toemergency requests onlySource alternate testing facilityoutside organisationFor example- Private lab orTownsville/RBH labsensure all UPS are charged andserviced.Ensure all iSTATs are placed onbattery recharger when not in use.Stock spare batteries (6-12batteries)
Lab. ManagerEngineering staff
Lab. Manager
Lab managerNUM's or person incharge of iSTAT onthe wards
Can function indefinityon emergency power
Hours
Loss of Watersupply
Major impact relating tothe Major ChemistryAnalyserUnable to maintain staffhygiene
No alternates to water
Use alternate solutions
• Ensure adequate stock available
Ensure adequate supplies of HexolEnsure adequate supplies bottledwater
Lab manager
Lab. ManagerInfection Control CNC
Can not operate
Temperaturemonitoring fails.
Unable to determineaccurate temperature ofBlood Stock Fridge andReagent Fridge.
Manual monitoring of fridgetemperature using portableprobe.
Install portable probe . Policy willdirect procedure if time becomesan issue
Develop policy on frequency oftemperature checksInform and educate staff
Lab. Manager
Lab. Manager
weeks
Failure of BloodBank Fridge
Unable to preserveintegrity of blood.
Transfer blood storeselsewhere
Investigate alternative storagesolutions.Private laboratories and Red Cross
Lab. Manager weeks
Page - 96 28/08/2013
PATHOLOGY SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task ResponsibilityHow long can youfunction without thisservice?
Equipment Failure Unable to process bloodsamples
Use alternate testing facilityoutside organisation
Source alternate testing facilityoutside organisationInform medical/nursing staff
Lab. Manager weeks
EquipmentFunction
Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon aspossible after disruption ofpower/failure of machines
Identify all equipment to bechecked
Inform and educate staff
Lab. Manager
Lab. Manager
Can not operate
Page - 97 28/08/2013
Business Continuity Plan
Pharmacy
PHARMACY
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Failure of Refrigerators /Deep Freeze
Spoilage ofpharmaceuticalsrequiring refrigeration /freezing
Ensure fridges and freezersconnected to emergencypower
Ensure fridges monitoredfor temperature
Check access to emergencygenerator power
Ensure On call pharmacistroster to respond tofridge/freezer failure alarm
Relocate stock to workingrefrigerators, cold rooms andfreezers
Pharmacy DirectorEngineering
Pharmacy Director
Pharmacy DirectorEngineerInfection Control Staff
within 30 minutes
within 30 minutes
one hour
Failure of air conditioning Unable to maintain airtemperature below 25'C
Ensure air conditioning forpharmacy connected toemergency power
Consider portable airconditionerHighlight potential inventoryfor destruction iftemperature extremeHigher load on fridges
Check availability ofemergency generator powerEnsure pharmacy is apriority area when airconditioning load shedscheduledArrange access to portableair conditionerContact Central Pharmacyfor direction
Monitor fridges
Pharmacy DirectorEngineering
Pharmacy DirectorEngineering
Pharmacist
Director of Pharmacy
Director of Pharmacy
six hours
Failure of computer IPharmacy notaccessible but localapplications okay
network printers notavailableiPharmacy access not atworkable speedPDE not available forimprest
Use fred5 label fordispensing, use hard copyrecoding for issues ifneededrestrict data entry toimmediate needs
print manual sheets asrequired or record manualdistributions
Have label available on localdrive
Have some label printers aslocal printers
print manual sheets as
Director of Pharmacy
Director of Pharmacy
Director of Pharmacy
pharmacy staff
Indefinite, more thanthree days will needcomplete stock take
when available
Indefinitely
Indefinitely
Page - 98 28/08/2013
PHARMACY
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
required or documentmanually
Indefinite, more thanthree days will needcomplete stock take
when availableNo lighting Not safe to operate Torch light available for
URGENT supply onlyTorches available insidegoods delivery door, afterhours room and safe
Director of Pharmacy URGENT supply only
No drug deliveries fromBrisbane
May not have drugavailable when required
Maintain stock levels toallow for supply chaininterruption of three daysObtain stock from SymbionTownsville
May need to cancelchemotherapy
Maintain max mins monthly
Ensure on line ordering fromSymbion is available
Director of Pharmacy
Director of Pharmacy
up to five days
Lack of pharmaciststaffing
Long delays in supply.Potential for increase inerror rateFatigue risk
Build in capacity intopharmacy staffing. Uselocum pharmacist.
Monitor staffing levels.Monitor availability of locums
Monitor working hours andrecall
Director of Pharmacy
Director of Pharmacy
Lack of pharmacy supportstaffing
Long delays in supply.Potential increase inerror rateFatigue risk
Build in capacity intopharmacy staffing. Usecasual staff.
Monitor staffing levelsMonitor availability of locumsMonitor working hours
Director of Pharmacy
No ability to deliver bulk IVfluids to wards
IV fluid may not beavailable when required
Adequate supply in wards
Backup forklift operators
Director of Pharmacy IV fluids bulk storage isnow a supply function
No proximity card accessto pharmacy
No access to pharmacyby prox card
nil
No forklift access to IV fluidsrestricted
Set locations of IV fluids instorage racks
Set locations of IV fluids instorage racks
Director of Pharmacy andSupply services
IV fluids bulk storage isnow a supply function
Page - 99 28/08/2013
.
Business Continuity Plan
Bowen Hospital – General & Clinical ServicesNOTE: The Standard Operating Procedures for the general wards and the MHHS Essential Services are to be used in conjunction with the specific procedures detailed below.
BOWEN HOSPITAL – GENERAL & CLINICAL SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
HBCIS access failure Unable to registerpatients
No Patient IDlabelsUnableUnable to accessUR numbers andexisting medicalrecords
Manual registration
Manual process
Good history taking
Adequate supply downtime formsData Entry at return of serviceHand write requests
Filing at return to service
Admin. staff
Admin and Clinicalstaff
Admin and Clinicalstaff
B
A&E Module failure Unable to utiliseTRIAGE, treatmentandadmission/discharge screens
Manual recording. Adequate Supply of downtime triageforms. Data Entry at return of service
Admin. Staff
C
Printing services Failure Unable to recordstatisticalrequirements
Retrospective data entry Check and update missing data Admin.& NursingStaff C
Computer failure Unable to printresults / labels etc.
Unable to generateID labels
Unable to trackpatient location andbed status
Manual recording - lead to adequate staffnumbersRecord patient details manually
Revert to manual process
Ensure adequate staffing to coverworkloadEnsure supply of HBCIS downtimeformsPre –print labels on existing patientsHand write on Medical record andspecimens as requiredUpdate patient location and bedstatus at regular intervals
BusinessManager/Admin.Staff
Administrative andnursing staff
Administrative andnursing staff
B
B
Page - 100 28/08/2013
BOWEN HOSPITAL – GENERAL & CLINICAL SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Telephone failure No internal /external telephonecommunications .
Access hand held radios from SES. UtiliseFire Panel Communication for internalcommunication.
contact SES DON or Delegate C
Cardex System 5hr battery back-upWhen back-uppower failureoccurs for extendedperiod. Access withCardex will not bepossible. SecurityVideo Surveillancewill discontinue.
Use back-up keys for door access. Inform and educate staff BusinessManager/DONNurse Unit Manager/Shift Team Leader
C
FAX Failure Unable to receiveor send patientinformation
Utilise alternate lines of communication Send patient information by courierDelay transfer of information untilservices resumed
Nurse UnitManager
Medical StaffAdministration Staff
B
Photocopier Failure Unable to copydocuments
Utilise alternate lines of communication Telephone information
Send original documents with patientand document in chartDelay transfer of information untilservices resumed
Nursing staff/Medical staff
B
Oxygen supplydisrupted
Use cylinder oxygen Ensure adequate suppliesEnsure all staff educated in cylinderchangeover.Consider co-locating high oxygenusers
OperationalOfficers
Wardsperson/Nurse UnitManager /Educator
Nursing staff/medical Staff
D
D
Failure of Refrigeration /cool rooms
Food spoilage referto Food Safety Plan
Essential fridges on emergency powerSource food off campus perhaps
Assess availability of emergencypower
Develop plan for preparation andtransport of food from other
Cook/BusinessManager
C
Page - 101 28/08/2013
BOWEN HOSPITAL – GENERAL & CLINICAL SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Consider long life shelf products appropriate sourcesPurchase dry / tinned foodConsider purchase of long life milkConsider purchase of bottled waterfor drinking Cook/Business
Manager
B
Refrigeration - Vaccine Drugs and medicalsupplies requiringrefrigeration maybecome unusable
Place drugs in refrigerators which areconnected to emergency power supply
Review emergency power outlets andmanage vaccines as per infectioncontrol/vaccine managementguidelines.Monitor refrigerator temperature withthermometerInform and educate staffConsider purchase of eskies andsupply of ice
Nurse Nurse UnitManager/Engineering staff
Nursing staff
Nurse UnitManagerNurse UnitManager
A -B
Failure of Dishwashers Refer to FoodSafety Plan
Use disposables Adequate supply disposables Cook/BusinessManager
C
Loss of communicationwith pre-hospital/transfer services andreferral centres
Unable tocommunicate withQAS
Unable tocommunicate withlocal GP’s
Use alternate communication channels
Develop an alternate referral/dischargeprocess
Use alternate communication strategy
Consider use of Mobile Phone ifnetwork is operational, use of 2-wayradio from community eg CouncilDevelop criteria for referral based onavailable services
Develop pro forma for requiredpatient informationLetter and pro forma sent with patientfor admissionDischarge summary sent with patientat dischargeUse QAS radio to contact ambulancecommunications
Use mobile phone if network isoperationalUse satellite phoneUse ambulance radio
Nursing Staff
Nursing Staff
B
C
Page - 102 28/08/2013
BOWEN HOSPITAL – GENERAL & CLINICAL SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Unable tocommunicate withClinical Coordinatorvia AMCOM repatient advice/transfer/ retrieval(RFDS, helicopter)
Unable tocommunicate withreceiving/ referringhospital
Use alternate communication strategy Instigate close observation of at riskpatients
Nursing Staff
Nursing Staff
C
B
C
Transport monitorsmalfunction
Unable to monitorcritically ill orunstable cardiacpatients in transit
Aim to have at least one complianttransport monitor or list of compliantmachines.Assess patients prior to critical dates.
Ensure one compliant transportmonitor available in central location
Schedule tests prior to critical dates
Assess pt need for transportCharge batteries
Nurse UnitManager
Medical staff
Nursing staff
D
B
Defibrillator malfunction Unable todefibrillate patients
Have compliant defibrillator available
Connect to emergency power
Use battery backup
Identify non compliant equipment
Aim to replace non compliantequipmentIdentify & re allocate compliantdefibrillatorInform & Educate staffIdentify existing emergency poweroutletsHave batteries fully charged
Nurse UnitManager
Nurse UnitManager
D
D
Medical equipmentfailure
Unable to providespecialised medicalequipmentBi-PAP/CPAPVentilators
Utilise emergency power
Manual processBattery back-up if availableManual ventilation
Manual processManual process
Check existing emergency poweroutlets
Fully charge batteriesEnsure adequate staff available formanual ventilationWarm water bathPerform visual examinationTreat prophylactically
Nurse UnitManager
A
Page - 103 28/08/2013
BOWEN HOSPITAL – GENERAL & CLINICAL SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Blood warmersSlit lamp
Plaster saw
Manual process Refer to ophthalmologistUse plaster cuttersApply a back slab
Nursing staffMedical staff C
Failure of Monitorsincluding cardiac &oximetry
Unable to identifyarrhythmias /oxygen saturation
Use on emergency power
Use battery backup
Increased nursing & medical observation
Check existing emergency poweroutletsIdentify non compliant equipmentAim to replace non compliantequipmentIdentify & position compliant monitorsensuring access to emergency powerEnsure adequate supply of batteries•Have batteries fully chargedIdentify & ensure adequate medical &nursing staff coveragePrioritise patients for monitoringInform and educate staff
Nurse UnitManager
Nurse UnitManagerNursing staff
D
D
Unable to providetransport services
Pathology servicesnot available
Identify and rationalise use of availablevehicles
Discontinue non-essential services
Develop a plan for centralising vehicles
Prioritise useNotify clients of potential fordisruption to normal servicesRe–admit at risk patients if necessary
Business manager C
Failure of EFTPOS fuelcard service
Arrange credit facility Liaise with local fuel distributor for credit facilities for fleet vehicles
Business manager C
Overcrowding ofhospital campus
Spread of disease Planned areas for habitation Allocate areas for use by public DON C
Staff dislocated fromfamily
Distress to staff Plan for accommodation Allocate staff accommodation (work &living for staff)
DON/NUM/BM C
Disease outbreak Infected persons Vaccines Plan for vaccines, fact sheets DON/MBH/AHS/TPHU
C
Waste Disposal Vector BorneDisease Infections
Sprays for insects. Antiseptics Assign contractors for pest control TPHU C
Lack of PublicKnowledge
Suspicion -Concerned Public
Stockpile of HP Material Stockpile PH MaterialMedia person to duties
BM/NUM/DON/TPHU
C
Loss of ability to protectstaff and patients
Duress alarms Provide alternative alert system for nursesAim to have fire alarms compliant
Purchase hand held audible alarmsand/or whistles
Nursing staff B
Page - 104 28/08/2013
BOWEN HOSPITAL – GENERAL & CLINICAL SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Fire alarmsProvide alternative power source foralarmsEnsure all staff have recent fire safetytraining
Check fire alarms
Ensure alarms are connected togenerator powerLiaise with Fire Department
BM/FSA
Insufficient staff Unable to providesafe level of care inthe event ofequipment failure
Unable to accesscomputerisedpathology/radiologyresults
Unable to regulatetemperature andenvironment
Roster additional staff
Revert to manual process
Enter data when system fixed
Use alternate cooling devices (eg.)
Calculate individual unit staffingrequirements
Identify human resources able to beon call and redeployed in the facilityAssess competence of on call staffCourier to collect results
Develop means for notification of lab& test resultsManual ordering testsEnsure retrospective data entry whencomputer services resumePosition fans for maximum benefitOpen Windows as a requirement
Director Of NursingNurse UnitManagerBusiness Manager
Operational Staff
Nurse UnitManager & Labstaff
Medical & nursingstaff
Nursing staff
B
B
Air conditioning failure Electrical or manual fan Identify patients requiring cooling,Use windows. Notify and informpatients and staff. All staff B
Wall suction failure Wall suction notavailable
Use alternate suction devices Assess need for and number ofportable suction units requiredConsider co-locating suctiondependent patientsEnsure adequate supply alternatedrainage systemsReplace drain suction with manualvacuum or drainage bottles
NUM
Nursing staff
B
Page - 105 28/08/2013
BOWEN HOSPITAL – GENERAL & CLINICAL SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Provide emergency oxygen/suction
Bloods to path as transport available
Ensure small oxygen cylinder withtwin-o-vac suction on resuscitationtrolleyEducate staff on use of alternatedevicesDevelop policy for formal laboratorytest
Nursing staff
Unable to use ISTAT Unable to diagnosepotential life-threateningconditions
Ensure access to emergency power Identify access to emergency poweroutlet
Nurse UnitManager /Engineering staff
D
Failure of 12 lead ECG machine
Unable to provide safe and secureenvironment
Use on battery power
Increased staff vigilance
Keep batteries fully charged onemergency powerInform and educate staffSchedule regular patient rounds
Nurse UnitManager /NursingStaff
D
Failure of EmergencyAlarms
Patients unable tosummonassistance
Utilise bells with capable patients Inform and educate Staff and Patients Nurse UnitManager
B
Failure of Patient callbuttons
Patients unable tosummonassistance
Refer to safety and security plan. More regular rounds of patients in thedepartment. Inform and educate staffand patients
Nurse UnitManager
B
Failure of InfusionPumps/Syringe Drivers
Staff unable totitrate medicationsand fluidsaccurately
Difficulties withlifting heavypatients – manualhandling injuries
Use on battery power if available.
Use burettes
Consider alternate administration routes.Identify alternate lifting devices
Charge on generator power if ableCharge batteries fully
Ensure adequate stock burettesProtocols for alternativeadministrationUse hydraulic lifting devices ifavailable
All staff Nursingstaff
C
Failure of lifting devices Use of slide sheets, pat slide, slidaperson etc.
All staff C
Macerators Unable to disposeof used pans andurinals
Utilise supply of washable pans andurinals. Manual Cleaning
Scrub and/or soak. Encourage use oftoilet as much as possible.
All clinical staff B
Page - 106 28/08/2013
Business Continuity PlanBowen Hospital – Utilities Services
BOWEN HOSPITAL - UTILITIES SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Loss of LPG supply
Unable to providecooking facilities
Secure LPG site and implementretrieval/disposal of hazardous material
Arrange urgent supply of portable LPGcylindersUse alternate energy source Gas Cook topor BBQ
Staff Education
Engineer to establish security of thesite and risk assess immediateneeds.Identify number of cylinders requiredand allocate as per priority listing.Arrange for supplier to fill storagetanks if not damagedIdentify alternate energy sources forcookingEducate staff on contingency plans
BM/Groundsman A
Oxygen supply disrupted Use cylinder oxygen Ensure adequate supplies BM/Groundsman A
Inability to supply mainspower to facilities
Unable to providehot water
Emergency power generation
Heat water with alternate energy sourceGas Quick heat water heater.Wash / clean with cold water
Ration use of emergency power
Identify existing supply of emergencypower generationRefer to power points/ outlets withemergency generation in each areaConfirm essential equipment onlyconnected to generator power outletsEnsure essential lights andequipment.Ensure access to extension leadsContact Contractor to ensureadequate fuel source for use ofgeneratorIdentify alternate energy sources forwater heatingIdentify cleaning processes that canuse cold water or use disposableware.Identify alternate washing regime forpatient hygiene Utilise "Bed Bath"productsEnsure fuel storage standards aremaintained.Identify generator load capacity
BM/Groundsman
Nurse UnitManager
BM/Groundsman
Nurse Unit
A
A
Page - 107 28/08/2013
BOWEN HOSPITAL - UTILITIES SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Use alternate power sources
Supply additional lighting
Discharge/ relocate patients within facility
Consider activation of MHHS Disaster Plan
Close Facility
Staff Education
Fully charge batteries on all essentialequipmentLocate/purchase torches/ lanternsand batteriesUse natural lighting -open windowsand doorsIdentify patients for discharge orrelocationConsult current MHHS Disaster Planfor processInform and educate staffLiaise with alternative serviceprovider for care of patientsTransfer patients out & close facility
Educate staff on contingencyarrangements
Manager
MHHS Manager
MHHS Manager/MedicalSuperintendentMHHS ManageronlyEducate staff oncontingencyarrangements
Loss of water supply forgeneral use, e.g., toilets,patient hygiene
Liaise with LocalCouncil Authorityre supplies ofwater.
Loss of MaceratorfunctionLoss of drinkingwater
ContingencyFailure
Ration water usage
Identify alternative water sources
Identify alternative supplies of drinkingwaterSee Worksheet "General"
Discharge/ relocate patients within facility
Consider activation of MHHS Disaster Plan
Use emergency supply
Close facility
Rationalise services and develop planfor water restriction
Source / cost alternate supplies, e.g. /Water tankers / Fire service supplyInitiate use of alternate supplyConsider purchase of bottled water
Unable to use.
Buy containers for storage ofdrinkable water
Identify patients for discharge orrelocationLiaise with local council / utilities reemergency water supplyLiaise with alternative serviceprovider for care of patient
MHHS Executive
ManagerEngineering
All clinical staff
MHHS Manager
A
D
A
Page - 108 28/08/2013
BOWEN HOSPITAL - UTILITIES SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Staff education Transfer patients out and close facilityEducate staff on contingency
Sewerage Unable to disposeof waste productsdue to waterfailure
Ensure facility wide plan Develop facility plan for wastedisposal
MHHS Executive D
Ensure Local Council andPublic Health Unitinvolvement.
Failure ofcontingency
Utilise “grey/used” water
Designate toilets to be used
Alternate toilet facilities
Discharge/ relocate patients within facility
Consider activation of MHHS Disaster Plan
Close facility
Staff education
Inform staff to save water after patienthygienePlace bucket for used water in eachtoilet cubicle for flushing purposesClose off toilets not for use and postsignsIdentify alternate toilet devices e.g.,porta loos, and number requiredSource supply / cost of alternatedevicesRinse with “grey/waste” water andchemical solutionInform staff of Infection Control policy
Identify patients for discharge orrelocationConsult current MHHS Disaster Planfor processLiaise with local council / utilities reemergency water supplyArrange for septic tank pumping truckto pump sewerage out of hospitalpipes
Liaise with alternative serviceprovider for care of patientTransfer patients out, close facilityEducate staff on contingency plans
Nurse UnitManagerOperationalServicesNUM
ManagerEngineering
Nurse UnitManager/ InfectionControl CNC
MHHS Manager /ManagerEngineering
MedicalSuperintendent
Nurse UnitManager /Managers
D
D
Power failure Mains power notavailable.Generator
Refer to mains power failure plan Inform and educate staff DON/NUM/BM/Engineering
B
Page - 109 28/08/2013
BOWEN HOSPITAL - UTILITIES SERVICES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
suppliesemergency power
Lighting failure Difficulties inpatientobservation andcare.
Increased risk forpatients and staff
Nosafety/evacuationlighting available
Utilise emergency lighting
Maximise natural lighting
Utilise alternate lighting
Maintain WH&S precautions
Provide additional portable lighting
Identify provision for emergencylighting
Relocate immobile patients to best litareasClean and maintain windows andfittingsEnsure blinds/curtains openEnsure adequate supply torches /battery operated lights and batteries
Clear patient areas, work areas andcorridors of all hazardsIdentify and source alternative lighting
Staff member to place lighting instrategic areas for safetyIssue clinical staff with torches
Engineering staff
Nursing staff
Nurse UnitManager
Nurse UnitManager /All staffNurse UnitManager /All staff
B
Page - 110 28/08/2013
Business Continuity Plan
Clermont Hospital - General
Clermont HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
HBCIS access failure Unable to registerpatients
Manual registration Adequate supply downtimeforms
Administration staff B
A&E Module failure No patient ID labels
Unable to utiliseTRIAGE, treatment andadmission/dischargescreensUnable to recordstatistical requirements
Manual process
Manual recording. Nowritten record of Ur nosmaintained on site
Retrospective data entry
Hand write requestsEnsure blank labels areavailableEnsure details are recordedin chart
Check and update missingdata
Administration staff
Administration StaffNursing Staff
B
C
Printing services Failure Unable to print results /labels etc.
Manual recording - lead toadequate staff numbers
Ensure adequate staffing tocover workload
Business ManagerAdministration staff
B
Computer failure Unable to generate IDlabels
Unable to track patientlocation and bed status
Record patient detailsmanually
Revert to manual process
Revert to manual process
Ensure supply of HBCISdowntime formsPre –print labels on existingpatientsHand write on blank labelsfor new admissionsUpdate patient location andbed status at regularintervalsUpdate patient diet lists andhave available for collectionby catering services
Administrative StaffNursing staff
Nursing staff
B
C
C
Telephone failure No internal / externaltelephonecommunications
Refer to facility widetelecommunications plan
Inform and educate staff Nurse Unit MangerDirector of NursingNursing staff
C
FAX Failure Unable to receive orsend patient information
Utilise alternate lines ofcommunication
Send patient information bycourierDelay transfer of informationuntil services resumed.
Nurse Unit MangerDirector of NursingAdministrative StaffNursing staff
B
B
Page - 111 28/08/2013
Clermont HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Photocopier Failure Unable to copydocuments
Utilise alternate lines ofcommunication
Telephone information
Send original documentswith patient and document inchartDelay transfer of informationuntil services resumed
Administrative StaffNursing staffNursing staffMedical staff
Medical staff
B
Oxygen supply disrupted Use cylinder oxygen Ensure adequate suppliesEnsure all staff educated incylinder changeover.Consider co-locating highoxygen users
Operational OfficersNurse Unit ManagerDirector of Nursing D
Failure of Refrigeration /cool rooms
Food spoilage refer toFood Safety Plan
Essential fridges onemergency powerSource food off campusperhaps
Consider long life shelfproducts
Assess availability ofemergency powerDevelop plan for preparationand transport of food fromother appropriate sourcesPurchase dry / tinned foodConsider purchase of longlife milkConsider purchase of bottledwater for drinking
Cook/Business ManagerFacility Manager
B
Refrigeration - Vaccine Drugs and medicalsupplies requiringrefrigeration maybecome unusable
Place drugs in refrigeratorswhich are connected toemergency power supply
Use Eskies and ice
Review emergency poweroutlets and managevaccines as per infectioncontrol/vaccine managementguidelines.Monitor refrigeratortemperature withthermometerUtilise SBVP EskyInform and educate staff
Nurse Unit ManagerDirector of NursingEngineering staff
Nurse Unit Manager
A
C
Failure of Dishwashers Refer to Food SafetyPlan
Use disposables Adequate supplydisposables
Cook/Business ManagerDirector of Nursing
C
Loss of communicationwith pre-hospital/ transferservices and referralcentres
Unable to communicatewith QAS
Use alternatecommunication channels
Consider use of MobilePhone if network isoperational, use of 2-wayradio from community egCouncil Nursing Staff
B
Page - 112 28/08/2013
Clermont HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Unable to communicatewith local GP’s
Unable to communicatewith Clinical Coordinatorvia AMCOM re patientadvice/ transfer/ retrieval(RFDS, helicopter)Unable to communicatewith receiving/ referringhospital
Develop an alternatereferral/discharge process
Use alternatecommunication strategy
Use alternatecommunication strategy
Develop criteria for referralbased on available servicesDevelop pro forma forrequired patient informationLetter and pro forma sentwith patient for admissionDischarge summary sentwith patient at dischargeUse QAS radio to contactambulance communicationsUse mobile phone if networkis operationalUse satellite phoneUse ambulance radio
Instigate close observationof at risk patients
Nursing Staff
Nursing Staff
C
C
C
Transport monitorsmalfunction
Unable to monitorcritically ill or unstablecardiac patients in transit
Aim to have at least onecompliant transport monitoror list of compliantmachines.Assess patients prior tocritical dates.
Ensure one complianttransport monitor availablein central location
Schedule tests prior tocritical datesAssess pt need for transportCharge batteries
Nurse Unit ManagerDirector of Nursing Medicalstaff
Medical staff
D
Defibrillator malfunction Unable to defibrillatepatients
Have compliant defibrillatoravailable
Connect to emergencypowerUse battery backup
Identify non compliantequipmentAim to replace noncompliant equipmentIdentify & re allocatecompliant defibrillatorInform & Educate staffIdentify existing emergencypower outletsHave batteries fully charged
Nurse Unit ManagerDirector of Nursing Medicalstaff
D
Medical equipment failure Unable to providespecialised medicalequipmentBi-PAP/CPAP
Utilise emergency power
Manual process
Check existing emergencypower outlets
Use black bag closed circuit
Nurse Unit ManagerDirector of Nursing
Nurse Unit Manager
C
Page - 113 28/08/2013
Clermont HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Ventilators
SpirometerSlit lamp
Plaster saw
Battery back-up if available
Manual ventilation
Use alternate equipment
Manual process
with 100% oxygenFully charge batteriesUse alternate oxygen drivenventilator
Ensure adequate staffavailable for manualventilationEnsure equipment isavailableUse peak flow metersPerform visual examinationTreat prophylacticallyRefer to ophthalmologistUse plaster cuttersApply a back slab
Director of NursingMedical staff
Nurse Unit ManagerDirector of NursingNursing staff
Nursing staff
Nursing staff
C
A
A
C
C
Failure of Monitorsincluding cardiac &oximetry
Unable to identifyarrhythmias / oxygensaturation
Use on emergency power
Use battery backup
Increased nursing &medical observation
Check existing emergencypower outlets
Identify non compliantequipmentAim to replace noncompliant equipmentIdentify & position compliantmonitors ensuring access toemergency powerEnsure adequate supply ofbatteries• Have batteriesfully chargedIdentify & ensure adequatemedical & nursing staffcoveragePrioritise patients formonitoringInform and educate staff
Nurse Unit ManagerDirector of Nursing
Nurse Unit ManagerDirector of Nursing
Nurse Unit ManagerDirector of NursingNurse Unit Manager Directorof Nursing
Nurse Unit ManagerDirector of Nursing
D
D
D
DD
Unable to providetransport services
Linen, pathologyservices not available
Identify and rationalise useof available vehicles
Develop a plan forcentralising vehicles
Business manager C
Page - 114 28/08/2013
Clermont HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Discontinue non-essentialservices
Prioritise useNotify clients of potential fordisruption to normal servicesRe–admit at risk patients ifnecessary
Medical staff C
Failure of EFTPOS fuelcard service
Arrange credit facility Liaise with local fueldistributor for credit facilitiesfor fleet vehicles
Business managerDirector of Nursing
C
Unable to transportsupplies from/to facility
Use alternate methods fortransport of supplies
Identify and engage externalcontractors
Business managerDirector of Nursing
C
Overcrowding of hospitalcampus
Spread of disease Planned areas forhabitation
Allocate areas for use bypublic
Director of Nursing C
Staff dislocated fromfamily
Distress to staff Plan for accommodation Allocate staffaccommodation (work &living for staff)
Director of NursingNurse Unit Manager Businessmanager
C
Disease outbreak Infected persons Vaccines Plan for vaccines, factsheets
Public Health Unit C
Waste Disposal Vector Borne DiseaseInfections
Sprays for insects.Antiseptics
Assign contractors for pestcontrol
Public Health Unit C
Lack of Public Knowledge Suspicion - ConcernedPublic
Stockpile of HP Material Stockpile PH MaterialMedia person to duties
Director of NursingMHHSPublic Health Unit
C
Loss of ability to protectstaff and patients
Duress alarms
Fire alarms
Provide alternative alertsystem for nurses
Aim to have fire alarmscompliant
Provide alternative powersource for alarms
Ensure all staff have recentfire safety training
Purchase hand held audiblealarmsConsider purchase ofwhistlesCheck fire alarms
Ensure alarms areconnected to generatorpowerLiaise with Fire Department
Nursing staff
Nurse Unit ManagerEngineering staffBusiness Manager
Manager Engineering
Director of NursingNurse Unit Manager BusinessManager
CWith appropriate
security
CWith appropriate
security
C
Insufficient staff Unable to provide safelevel of care in the event
Roster additional staff Calculate individual unitstaffing requirements
Director of NursingNurse Unit Manager Business B
Page - 115 28/08/2013
Clermont HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
of equipment failure
Unable to accesscomputerisedpathology/radiologyresults
Revert to manual process
Enter data when systemfixed
Identify human resourcesable to be on call andredeployed in the facilityAssess competence of oncall staffCourier to collect results
Develop means fornotification of lab & testresultsManual ordering tests
Ensure retrospective dataentry when computerservices resume
Manager
Operational Staff
Nurse Unit Manager & Labstaff
Medical StaffNursing staffNursing staff
B
B
Air conditioning failure Unable to regulatetemperature andenvironment
Use alternate coolingdevices (eg.) Electrical ormanual fan
Refer to facility wide plan
Position fans for maximumbenefit
Identify patients requiringcoolingInform and educate staff
Nursing staff
Nursing staff
Nurse Unit Manager
B
B
Wall suction failure Wall suction notavailable
Use alternate suctiondevices
Provide emergencyoxygen/suction
Assess need for and numberof portable suction unitsrequiredConsider co-locating suctiondependent patientsEnsure adequate supplyalternate drainage systemsReplace drain suction withmanual vacuum or drainagebottlesEnsure small oxygencylinder with twin-o-vacsuction on resuscitationtrolleyEducate staff on use ofalternate devices
Nurse Unit Manager
Nursing staff
Nursing staff
Nurse Unit ManagerDirector of Nursing
B
B
D
Page - 116 28/08/2013
Clermont HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Unable to use ISTAT Bloods to path Develop policy for formallaboratory test
Medical staff C
Failure of 12 lead ECGmachine
Unable to diagnosepotential life-threateningconditions
Ensure access toemergency power
Use on battery power
Identify access toemergency power outlet
Keep batteries fully chargedon emergency powerIdentify location ofalternative ECG machinesInform and educate staff
Nurse Unit ManagerDirector of NursingEngineering staff
Nursing staff
Nurse Unit Manager
D
D
Failure of EmergencyAlarms
Unable to provide safeand secure environment
Increased staff vigilance
Refer to safety and securityplan.
Schedule regular patientroundsInform and educate Staff
Nursing staff
Nurse Unit ManagerDirector of Nursing
C
Failure of Patient callbuttons
Patients unable tosummon assistance
Refer to safety and securityplan.
More regular rounds ofpatients in the department.Inform and educate staff
Nurse Unit ManagerDirector of Nursing
C
Failure of InfusionPumps/Syringe Drivers
Staff unable to titratemedications and fluidsaccurately
Use on battery power ifavailableUse burettes
Consider alternateadministration routes.
Charge on generator powerif ableCharge batteries fullyEnsure adequate stockburettesProtocols for alternativeadministration
All staffNursing staff
Nursing staffMedical staff
C
C
CFailure of lifting devices Difficulties with lifting
heavy patients – manualhandling injuries
Identify alternate liftingdevices
Use hydraulic lifting devicesif availableUse of slide sheets, patslide, slida person etc.Ensure staff trained inmanual handling
All staff
All staff
Nurse Unit Manager Back carefacilitator/Hinterland Educator
C
Pan room hopper Unable to clean bedpans / urinals adequately
Single patient use bedpans/urinals
Purchase sufficient forimmobile patientsRinse with “grey/waste”water and disinfect withchemical solutionInform staff of InfectionControl policy
Nurse Unit ManagerAll staff
Nurse Unit Manager Directorof NursingInfection Control CNC forMHHS
C
C
Page - 117 28/08/2013
Business Continuity PlanClermont Hospital – Utilities Services
CLERMONT HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Loss of LPG supply
Unable to providecooking facilities
Unable to provide hotwater
Secure LPG site andimplement retrieval/disposalof hazardous materialArrange urgent supply ofportable LPG cylinders
Use alternate energysource Gas Cook top orBBQHeat water with alternateenergy source Gas Quickheat water heater.Wash / clean with coldwater
Dishwasher heats ownwaterStaff Education
Engineer to establishsecurity of the site and riskassess immediate needs.Identify number of cylindersrequired and allocate as perpriority listingArrange for supplier to fillstorage tanks if notdamagedIdentify alternate energysources for cooking
Identify alternate energysources for water heating
Identify cleaning processesthat can use cold water oruse disposable ware
Identify alternate washingregime for patient hygieneNo remedial action required
Educate staff oncontingency plans
Manager Engineering/Director of Nursing
Manager Engineering
Manager Engineering
Business manager/Director ofNursing
Manager Engineering
Manager EngineeringBusiness ManagerDirector of NursingBusinessManager/Cook/Director ofNursing
A
A
A
A
B
B
Oxygen supply disrupted Use cylinder oxygen Ensure adequate supplies Operational Officers/ BusinessManager
A
Inability to supply mainspower to facilities
Emergency powergeneration
Identify existing supply ofemergency powergenerationRefer to power points/outlets with emergencygeneration in each area
Manager Engineering
Manager EngineeringDirector of Nurse UnitManager
A
Page - 118 28/08/2013
CLERMONT HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Ration use of emergencypowerUse alternate powersourcesSupply additional lighting
Discharge/ relocate patientswithin facility
Confirm essential equipmentonly connected to generatorpower outletsEnsure essential lights andequipment supplied.Consider need to purchaseextension leadsDevelop a procedure for useof emergency power in eacharea and inform staffContactEngineering/Contractor toensure adequate fuel sourcefor use of generatorEnsure fuel storagestandards are maintainedIdentify generator loadcapacityFully charge batteries on allessential equipmentLocate/purchase torches/lanterns and batteriesInform and educate staff
Manager Engineering
Nurse Unit ManagerNurse Unit Manager
Manager Engineering
Manager Engineering
Nurse Unit Manager
Nurse Unit Manager
All Managers
A
A
A
A
A
A
Consider activation ofMHHS Disaster PlanClose Facility
Staff Education
Consult current MHHSDisaster Plan for processLiaise with alternativeservice provider for care ofpatientsTransfer patients out & closefacilityEducate staff oncontingency arrangements
MHHS Manager
MHHS ManagerMedical Superintendent
MHHS Manager only
Nurse Unit Manager
A
A
Loss of water supply forgeneral use, e.g., toilets,patient hygiene
Liaise with LocalCouncil Authority resupplies of water.
Ration water usage
Identify alternative watersources
Rationalise services anddevelop plan for waterrestrictionSource / cost alternatesupplies, e.g. / Watertankers / Fire service supply
MHHS ExecutiveManager EngineeringDirector of Nursing
A
Page - 119 28/08/2013
CLERMONT HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Loss of drinking water
Contingency Failure
Identify alternative suppliesof drinking water
Discharge/ relocate patientswithin facility
Consider activation ofMHHS Disaster PlanUse emergency supply
Close facility
Staff education
Initiate use of alternatesupplyConsider purchase of bottledwaterLiaise with Renal DialysisUnit to save empty dialysatecontainers for water storageBuy containers for storage ofdrinkable waterIdentify patients fordischarge or relocationConsult current MHHSDisaster Plan for processLiaise with local council /utilities re emergency watersupplyLiaise with alternativeservice provider for care ofpatientTransfer patients out andclose facilityEducate staff oncontingency
Manager Engineering
MHHS ExecutiveManager Stores
Business Manager
Medical Superintendent
MHHS Manager
MHHS Manager
MHHS Manager / MedicalSuperintendent
A
A
A
A
Sewerage Unable to dispose ofwaste products due towater failure
Ensure facility wide plan Develop facility plan forwaste disposal
MHHS Executive D
Ensure Local council andPublic Health Unitinvolvement.
Utilise “grey/used” water
Designate toilets to be used
Alternate toilet facilities
Single patient use bedpans/
Inform staff to save waterafter patient hygienePlace bucket for used waterin each toilet cubicle forflushing purposesClose off toilets not for useand post signsIdentify alternate toiletdevices e.g., porta loos, andnumber requiredSource supply / cost ofalternate devicesPurchase sufficient for
Nurse Unit ManagerOperational Services
Nurse Unit ManagerDirector of Nursing
Manager Engineering
Manager Engineering
Nurse Unit Manager
D
D
D
D
Page - 120 28/08/2013
CLERMONT HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Failure of contingency
urinals
Discharge/ relocate patientswithin facilityConsider activation ofMHHS Disaster Plan
Close facility
Staff education
immobile patientsRinse with “grey/waste”water and chemical solutionInform staff of InfectionControl policyIdentify patients fordischarge or relocationConsult current MHHSDisaster Plan for processLiaise with local council /utilities re emergency watersupplyArrange for septic tankpumping truck to pumpsewerage out of hospitalpipesLiaise with alternativeservice provider for care ofpatientTransfer patients out, closefacilityEducate staff oncontingency plans
All staff
Medical Superintendent
MHHS ManagerManager Engineering
Manager Engineering
Medical Superintendent
Nurse Unit Manager/FacilityManager/ Managers
D
D
D
Power failure Mains power notavailable. Generatorsupplies emergencypower
Refer to mains powerfailure plan
Inform and educate staff DON/ NUM/BM/Engineering B
Lighting failure Difficulties in patientobservation and care.
Increased risk forpatients and staff
Utilise emergency lighting
Maximise natural lighting
Utilise alternate lighting
Maintain WH&Sprecautions
Identify provision foremergency lightingRelocate immobile patientsto best lit areasClean and maintain windowsand fittingsEnsure blinds/curtains openEnsure adequate supplytorches / battery operatedlights and batteriesClear patient areas, workareas and corridors of all
Engineering staff
Nursing staff
Operational Staff
All staffNurse Unit Manager/Directorof NursingNUM/ All staff
B
B
Page - 121 28/08/2013
CLERMONT HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
No safety/evacuationlighting available
Provide additional portablelighting
hazardsIdentify and sourcealternative lightingStaff member to placelighting in strategic areas forsafetyIssue clinical staff withtorches
NUM/All staff
Page - 122 28/08/2013
Business Continuity Plan
Monash Lodge Clermont - General
Monash Lodge - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
HBCIS access failure Unable to registerpatients
Manual registration Adequate supply downtimeforms
Administration staff B
Printing services Failure Unable to print results /labels etc.
Manual recording - lead toadequate staff numbers
Ensure adequate staffing tocover workload
Business ManagerAdministration staff
B
Computer failure Unable to generate IDlabels
Unable to track patientlocation and bed status
Record patient detailsmanually
Revert to manual process
Revert to manual process
Ensure supply of HBCISdowntime formsPre –print labels on existingpatientsHand write on blank labelsfor new admissionsUpdate patient location andbed status at regularintervalsUpdate patient diet lists andhave available for collectionby catering services
Administrative StaffNursing staff
Nursing staff
B
C
C
Telephone failure No internal / externaltelephonecommunications
Refer to facility widetelecommunications plan
Inform and educate staff Clinical NurseNurse Unit ManagerDirector of NursingNursing staff
C
FAX Failure Unable to receive orsend patient information
Utilise alternate lines ofcommunication
Send patient information bycourierDelay transfer of informationuntil services resumed.
Clinical NurseAdministrative StaffNursing staff
B
BPhotocopier Failure Unable to copy
documentsUtilise alternate lines ofcommunication
Telephone information
Send original documentswith patient and document inchartDelay transfer of informationuntil services resumed
Administrative StaffNursing staffNursing staffMedical staff
Medical staff
B
Oxygen supply disrupted Use cylinder oxygen Ensure adequate suppliesEnsure all staff educated in
Operational OfficersClinical Nurse
Page - 123 28/08/2013
Monash Lodge - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
cylinder changeover.Consider co-locating highoxygen users
Nurse Unit Manager D
Failure of Refrigeration /cool rooms
Food spoilage refer toFood Safety Plan
Essential fridges onemergency powerSource food off campusperhaps
Consider long life shelfproducts
Assess availability ofemergency powerDevelop plan for preparationand transport of food fromother appropriate sourcesPurchase dry / tinned foodConsider purchase of longlife milkConsider purchase of bottledwater for drinking
Cook/Business Manager/Director of Nursing
B
Refrigeration - Drugs and medicalsupplies requiringrefrigeration maybecome unusable
Place drugs in refrigeratorswhich are connected toemergency power supply
Use Eskies and ice
Review emergency poweroutlets and manage as perinfection control/management guidelines.Monitor refrigeratortemperature withthermometerUtilise SBVP EskyInform and educate staff
Clinical NurseNurse UnitManager/Engineering staff
Clinical Nurse
A
C
Failure of Dishwashers Refer to Food SafetyPlan
Use disposables Adequate supplydisposables
Cook/Business Manager C
Loss of communicationwith pre-hospital/ transferservices and referralcentres
Unable to communicatewith QAS
Unable to communicatewith local GP’s
Unable to communicate
Use alternatecommunication channels
Develop an alternatereferral/discharge process
Use alternate
Consider use of MobilePhone if network isoperational, use of 2-wayradio from community egCouncilDevelop criteria for referralbased on available servicesDevelop pro forma forrequired patient informationLetter and pro forma sentwith patient for admissionDischarge summary sentwith patient at dischargeUse QAS radio to contact
Nursing Staff
Nursing Staff
B
C
C
Page - 124 28/08/2013
Monash Lodge - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
with receiving/ referringhospital
communication strategy
Use alternatecommunication strategy
ambulance communicationsUse mobile phone if networkis operationalUse satellite phoneUse ambulance radio
Instigate close observationof at risk patients
Nursing Staff C
Transport monitorsmalfunction
Unable to monitorcritically ill or unstablecardiac patients in transit
Aim to have at least onecompliant transport monitoror list of compliantmachines.Assess patients prior tocritical dates.
Ensure one complianttransport monitor availablein central location
Schedule tests prior tocritical datesAssess pt need for transportCharge batteries
Clinical Nurse, Nurse UnitManager Medical staff
Medical staff
D
Medical equipment failure
Failure of Monitorsoximetry
Unable to identifyarrhythmias / oxygensaturation
Use on emergency powerUse battery backup
Increased nursing &medical observation
Check existing emergencypower outlets
Identify non compliantequipmentAim to replace noncompliant equipmentIdentify & position compliantmonitors ensuring access toemergency powerEnsure adequate supply ofbatteries• Have batteriesfully chargedIdentify & ensure adequatemedical & nursing staffcoveragePrioritise patients formonitoringInform and educate staff
Clinical Nurse Consultant
Clinical Nurse Consultant
Clinical Nurse Consultant
Clinical Nurse ConsultantDirector of Nursing
Clinical Nurse ConsultantClinical Nurse Consultant
D
D
D
DD
Page - 125 28/08/2013
Monash Lodge - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Unable to providetransport services
Linen, pathologyservices not available
Identify and rationalise useof available vehicles
Discontinue non-essentialservices
Develop a plan forcentralising vehiclesPrioritise useNotify clients of potential fordisruption to normal servicesRe–admit at risk patients ifnecessary
Business managerDirector of Nursing
Medical staff
C
C
Failure of EFTPOS fuelcard service
Arrange credit facility Liaise with local fueldistributor for credit facilitiesfor fleet vehicles
Business manager C
Unable to transportsupplies from/to facility
Use alternate methods fortransport of supplies
Identify and engage externalcontractors
Business manager C
Overcrowding of MonashLodgecampus
Spread of disease Planned areas forhabitation
Allocate areas for use bypublic
Director of Nursing C
Staff dislocated fromfamily
Distress to staff Plan for accommodation Allocate staffaccommodation (work &living for staff)
Director of NursingClinical NurseBusiness manager
C
Disease outbreak Infected persons Vaccines Plan for vaccines, factsheets
Public Health UnitDirector of Nursing
C
Waste Disposal Vector Borne DiseaseInfections
Sprays for insects.Antiseptics
Assign contractors for pestcontrol
Public Health UnitDirector of Nursing
C
Lack of Public Knowledge Suspicion - ConcernedPublic
Stockpile of HP Material Stockpile PH MaterialMedia person to duties
Director of NursingMHHSPublic Health Unit
C
Loss of ability to protectstaff and patients
Duress alarms
Fire alarms
Provide alternative alertsystem for nurses
Aim to have fire alarmscompliant
Provide alternative powersource for alarms
Ensure all staff have recentfire safety training
Purchase hand held audiblealarmsConsider purchase ofwhistlesCheck fire alarms
Ensure alarms areconnected to generatorpowerLiaise with Fire Department
Nursing staff
Clinical NurseNurse Unit ManagerDirector of Nursing
Engineering staffBusiness Manager
Manager Engineering
Director of NursingClinical Nurse /Business mgr
CWith appropriate
security
CWith appropriate
security
C
Page - 126 28/08/2013
Monash Lodge - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Insufficient staff Unable to provide safelevel of care in the eventof equipment failure
Unable to accesscomputerisedpathology/radiologyresults
Roster additional staff
Revert to manual process
Enter data when systemfixed
Calculate individual unitstaffing requirements
Identify human resourcesable to be on call andredeployed in the facilityAssess competence of oncall staffCourier to collect results
Develop means fornotification of lab & testresultsManual ordering tests
Ensure retrospective dataentry when computerservices resume
Director of NursingClinical Nurse, Nurse UnitManager Business Manager
Operational Staff
Clinical Nurse & Lab staff
Medical StaffNursing staffNursing staff
B
B
B
Air conditioning failure Unable to regulatetemperature andenvironment
Use alternate coolingdevices (eg.) Electrical ormanual fan
Refer to facility wide plan
Position fans for maximumbenefit
Identify patients requiringcoolingInform and educate staff
Nursing staff
Nursing staff
Clinical NurseNurse Unit Manager
B
B
Educate staff on use ofalternate devices
Unable to use ISTAT Bloods to path Develop policy for formallaboratory test
Medical staff C
Failure of EmergencyAlarms
Unable to provide safeand secure environment
Increased staff vigilance
Refer to safety and securityplan.
Schedule regular patientroundsInform and educate Staff
Nursing staff
Clinical NurseC
Failure of Patient callbuttons
Patients unable tosummon assistance
Refer to safety and securityplan.
More regular rounds ofpatients in the department.Inform and educate staff
Clinical Nurse C
Page - 127 28/08/2013
Monash Lodge - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Failure of lifting devices Difficulties with liftingheavy patients – manualhandling injuries
Identify alternate liftingdevices
Use hydraulic lifting devicesif availableUse of slide sheets, patslide,slida person etc.Ensure staff trained inmanual handling
All staff
All staff
CNBack care facilitatorHinterland Educator
C
Pan room hopper Unable to clean bedpans / urinals adequately
Single patient use bedpans/urinals
Purchase sufficient forimmobile patientsRinse with “grey/waste”water and disinfect withchemical solutionInform staff of InfectionControl policy
Clinical Nurse
All staff
CNInfection Control CNC
C
C
Page - 128 28/08/2013
Business Continuity PlanMonash Lodge Clermont – Utilities Services
MONASH LODGE - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Loss of LPG supply
Unable to providecooking facilities
Unable to provide hotwater
Secure LPG site andimplement retrieval/disposalof hazardous materialArrange urgent supply ofportable LPG cylinders
Use alternate energysource Gas Cook top orBBQHeat water with alternateenergy source Gas Quickheat water heater.Wash / clean with coldwater
Dishwasher heats ownwaterStaff Education
Engineer to establishsecurity of the site and riskassess immediate needs.Identify number of cylindersrequired and allocate as perpriority listingArrange for supplier to fillstorage tanks if notdamagedIdentify alternate energysources for cooking
Identify alternate energysources for water heating
Identify cleaning processesthat can use cold water oruse disposable ware
Identify alternate washingregime for patient hygieneNo remedial action required
Educate staff oncontingency plans
Manager EngineeringDirector of Nursing
Manager EngineeringDirector of Nursing
Manager Engineering
Business manager
Manager Engineering
Manager EngineeringBusiness ManagerClinical NurseBusiness Manager/Cook
A
A
A
A
B
B
Oxygen supply disrupted Use cylinder oxygen Ensure adequate supplies Operational Officers/ BusinessManager/Director of Nursing
A
Inability to supply mainspower to facilities
Emergency powergeneration
Identify existing supply ofemergency powergenerationRefer to power points/outlets with emergencygeneration in each area
Manager Engineering
Manager EngineeringClinical NurseClinical Nurse
A
Page - 129 28/08/2013
MONASH LODGE - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Ration use of emergencypowerUse alternate powersourcesSupply additional lighting
Discharge/ relocate patientswithin facility
Confirm essential equipmentonly connected to generatorpower outletsEnsure essential lights andequipment supplied.Consider need to purchaseextension leadsDevelop a procedure for useof emergency power in eacharea and inform staffContactEngineering/Contractor toensure adequate fuel sourcefor use of generatorEnsure fuel storagestandards are maintainedIdentify generator loadcapacityFully charge batteries on allessential equipmentLocate/purchase torches/lanterns and batteriesInform and educate staff
Manager Engineering
Clinical NurseClinical Nurse
Manager Engineering
Manager Engineering
Nurse Unit Manager
Nurse Unit Manager
All Managers
A
A
A
A
A
A
Consider activation ofMHHS Disaster PlanClose Facility
Staff Education
Consult current MHHSDisaster Plan for processLiaise with alternativeservice provider for care ofpatientsTransfer patients out & closefacilityEducate staff oncontingency arrangements
MHHS Manager
MHHS ManagerMedical Superintendent
MHHS Manager only
Clinical Nurse, Nurse UnitManager
A
A
Loss of water supply forgeneral use, e.g., toilets,patient hygiene
Liaise with LocalCouncil Authority resupplies of water.
Ration water usage
Identify alternative watersources
Rationalise services anddevelop plan for waterrestrictionSource / cost alternatesupplies, e.g. / Watertankers / Fire service supply
MHHS ExecutiveManager EngineeringDirector of Nursing
A
Page - 130 28/08/2013
MONASH LODGE - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Loss of drinking water
Contingency Failure
Identify alternative suppliesof drinking water
Discharge/ relocate patientswithin facility
Consider activation ofMHHS Disaster PlanUse emergency supply
Close facility
Staff education
Initiate use of alternatesupplyConsider purchase of bottledwaterLiaise with Renal DialysisUnit to save empty dialysatecontainers for water storageBuy containers for storage ofdrinkable waterIdentify patients fordischarge or relocationConsult current MHHSDisaster Plan for processLiaise with local council /utilities re emergency watersupplyLiaise with alternativeservice provider for care ofpatientTransfer patients out andclose facilityEducate staff oncontingency
Manager Engineering
MHHS ExecutiveManager Stores
Business Manager
Medical Superintendent
MHHS Manager
MHHS Manager
MHHS Manager / MedicalSuperintendent
A
A
A
A
Sewerage Unable to dispose ofwaste products due towater failure
Ensure facility wide plan Develop facility plan forwaste disposal
MHHS Executive D
Ensure Local council andPublic Health Unitinvolvement.
Utilise “grey/used” water
Designate toilets to be used
Alternate toilet facilities
Single patient use bedpans/
Inform staff to save waterafter patient hygienePlace bucket for used waterin each toilet cubicle forflushing purposesClose off toilets not for useand post signsIdentify alternate toiletdevices e.g., porta loos, andnumber requiredSource supply / cost ofalternate devicesPurchase sufficient for
Clinical Nurse Consultant
Operational Services
Clinical Nurse, Nurse UnitManagerDirector of Nursing
Manager Engineering
Manager Engineering
D
D
D
D
Page - 131 28/08/2013
MONASH LODGE - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Failure of contingency
urinals
Discharge/ relocate patientswithin facilityConsider activation ofMHHS Disaster Plan
Close facility
Staff education
immobile patientsRinse with “grey/waste”water and chemical solutionInform staff of InfectionControl policyIdentify patients fordischarge or relocationConsult current MHHSDisaster Plan for processLiaise with local council /utilities re emergency watersupplyArrange for septic tankpumping truck to pumpsewerage out of hospitalpipesLiaise with alternativeservice provider for care ofpatientTransfer patients out, closefacilityEducate staff oncontingency plans
Clinical Nurse, Nurse UnitManagerDirector of Nursing
All staff
Medical Superintendent
MHHS ManagerManager Engineering
Manager Engineering
Medical Superintendent
Clinical Nurse / Managers
D
D
D
Power failure Mains power notavailable. Generatorsupplies emergencypower
Refer to mains powerfailure plan
Inform and educate staff DON/ NUMBM/Engineering B
Lighting failure Difficulties in patientobservation and care.
Utilise emergency lighting
Maximise natural lighting
Utilise alternate lighting
Identify provision foremergency lightingRelocate immobile patientsto best lit areasClean and maintain windowsand fittingsEnsure blinds/curtains openEnsure adequate supplytorches / battery operatedlights and batteries
Engineering staff
Nursing staff
Operational Staff
All staffClinical Nurse, Nurse UnitManagerDirector of Nursing
B
B
Page - 132 28/08/2013
MONASH LODGE - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Increased risk forpatients and staff
No safety/evacuationlighting available
Maintain WH&Sprecautions
Provide additional portablelighting
Clear patient areas, workareas and corridors of allhazardsIdentify and sourcealternative lightingStaff member to placelighting in strategic areas forsafetyIssue clinical staff withtorches
CN / NUM/DON All staff
CN/NUM/DON/All staff
Page - 133 28/08/2013
Business Continuity Plan
Collinsville Hospital - General
COLLINSVILLE HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
HBCIS access failure Unable to registerpatients
Manual registration Adequate supply downtimeforms
Administration staff B
A&E Module failure No patient ID labels
Unable to utiliseTRIAGE, treatment andadmission/dischargescreensUnable to recordstatistical requirements
Manual process
Manual recording. Nowritten record of Ur nosmaintained on site
Retrospective data entry
Hand write requestsEnsure blank labels areavailableEnsure details are recordedin chart
Check and update missingdata
Administration staff
Administration StaffNursing Staff
B
C
Printing services Failure Unable to print results /labels etc.
Manual recording - lead toadequate staff numbers
Ensure adequate staffing tocover workload
Business ManagerAdministration staff
B
Computer failure Unable to generate IDlabels
Unable to track patientlocation and bed status
Unable to provide patientdietary requirements
Record patient detailsmanually
Revert to manual process
Revert to manual process
Ensure supply of HBCISdowntime formsPre –print labels on existingpatientsHand write on blank labelsfor new admissionsUpdate patient location andbed status at regularintervalsUpdate patient diet lists andhave available for collectionby catering services
Administrative StaffNursing staff
Nursing staff
B
C
C
Telephone failure No internal / externaltelephonecommunications
Refer to facility widetelecommunications plan
Inform and educate staff NUM/DONNursing staff
C
Tape recorder failure Unable to pre-recordpatient handover
Revert to verbal handover Designate time, venue andprocedure for verbal hand-over
NUM/DON C
FAX Failure Unable to receive orsend patient information
Utilise alternate lines ofcommunication
Send patient information bycourier
Nurse Unit ManagerAdministrative Staff
B
Page - 134 28/08/2013
COLLINSVILLE HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Delay transfer of informationuntil services resumed.
Nursing staffB
Photocopier Failure Unable to copydocuments
Utilise alternate lines ofcommunication
Telephone information
Send original documentswith patient and document inchartDelay transfer of informationuntil services resumed
Administrative StaffNursing staffNursing staffMedical staff
Medical staff
B
Oxygen supply disrupted Use cylinder oxygen Ensure adequate suppliesEnsure all staff educated incylinder changeover.Consider co-locating highoxygen users
Operational OfficersClinical Nurse Consultant
D
Failure of Refrigeration /cool rooms
Food spoilage refer toFood Safety Plan
Essential fridges onemergency powerSource food off campusperhaps
Consider long life shelfproducts
Assess availability ofemergency powerDevelop plan for preparationand transport of food fromother appropriate sourcesPurchase dry / tinned foodConsider purchase of longlife milkConsider purchase of bottledwater for drinking
Cook/Business Manager B
Refrigeration - Vaccine Drugs and medicalsupplies requiringrefrigeration maybecome unusable
Place drugs in refrigeratorswhich are connected toemergency power supply
Use Eskies and ice
Review emergency poweroutlets and managevaccines as per infectioncontrol/vaccine managementguidelines.Monitor refrigeratortemperature withthermometerUtilise SBVP EskyInform and educate staff
Clinical NurseConsultant/Engineering staff
Nurse Unit Manager/DON
A
C
Failure of Dishwashers Refer to Food SafetyPlan
Use disposables Adequate supplydisposables
Cook/Business Manager C
Loss of communicationwith pre-hospital/ transfer
Unable to communicatewith QAS
Use alternatecommunication channels
Consider use of MobilePhone if network is
B
Page - 135 28/08/2013
COLLINSVILLE HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
services and referralcentres
Unable to communicatewith local GP’s
Unable to communicatewith Clinical Coordinatorvia AMCOM re patientadvice/ transfer/ retrieval(RFDS, helicopter)Unable to communicatewith receiving/ referringhospital
Develop an alternatereferral/discharge process
Use alternatecommunication strategy
Use alternatecommunication strategy
operational, use of 2-wayradio from community egCouncilDevelop criteria for referralbased on available servicesDevelop pro forma forrequired patient informationLetter and pro forma sentwith patient for admissionDischarge summary sentwith patient at dischargeUse QAS radio to contactambulance communicationsUse mobile phone if networkis operationalUse satellite phoneUse ambulance radio
Instigate close observationof at risk patients
Nursing Staff
Nursing Staff
Nursing Staff
C
C
C
Transport monitorsmalfunction
Unable to monitorcritically ill or unstablecardiac patients in transit
Aim to have at least onecompliant transport monitoror list of compliantmachines.Assess patients prior tocritical dates.
Ensure one complianttransport monitor availablein central location
Schedule tests prior tocritical datesAssess pt need for transportCharge batteries
NUM/DON Medical staff
Medical staff
D
Defibrillator malfunction Unable to defibrillatepatients
Have compliant defibrillatoravailable
Connect to emergencypowerUse battery backup
Identify non compliantequipmentAim to replace noncompliant equipmentIdentify & re allocatecompliant defibrillatorInform & Educate staffIdentify existing emergencypower outletsHave batteries fully charged
NUM/DON Medical staff D
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COLLINSVILLE HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Medical equipment failure Unable to providespecialised medicalequipmentBi-PAP/CPAP
Ventilators
Blood warmersBiers machineLevel 1 transfuser
SpirometerSlit lamp
Plaster saw
Utilise emergency power
Manual process
Battery back-up if available
Manual ventilation
Use alternate equipment
Manual processManual process
Manual process
Check existing emergencypower outlets
Use black bag closed circuitwith 100% oxygenFully charge batteriesUse alternate oxygen drivenventilator
Ensure adequate staffavailable for manualventilationEnsure equipment isavailableWarm water bathDouble cuff tourniquetBlood pumping set andpressure bagUse peak flow metersPerform visual examinationTreat prophylacticallyRefer to ophthalmologistUse plaster cuttersApply a back slab
NUM/DON
NUM/DON Medical staff
NUM/DON
Nursing staff
Nursing staff
Nursing staff
C
C
A
A
C
C
Failure of Monitorsincluding cardiac &oximetry
Unable to identifyarrhythmias / oxygensaturation
Use on emergency power
Use battery backup
Increased nursing &medical observation
Check existing emergencypower outlets
Identify non compliantequipmentAim to replace noncompliant equipmentIdentify & position compliantmonitors ensuring access toemergency powerEnsure adequate supply ofbatteries• Have batteriesfully chargedIdentify & ensure adequatemedical & nursing staff
DON/NUM
NUM/DON
NUM
Director of Nursing
D
D
D
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COLLINSVILLE HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
coveragePrioritise patients formonitoringInform and educate staff
NUM/DONNUM/DON
DD
Unable to providetransport services
Linen, pathologyservices not available
Identify and rationalise useof available vehicles
Discontinue non-essentialservices
Develop a plan forcentralising vehiclesPrioritise useNotify clients of potential fordisruption to normal servicesRe–admit at risk patients ifnecessary
Business manager
Medical staff
C
C
Failure of EFTPOS fuelcard service
Arrange credit facility Liaise with local fueldistributor for credit facilitiesfor fleet vehicles
Business manager C
Unable to transportsupplies from/to facility
Use alternate methods fortransport of supplies
Identify and engage externalcontractors
Business manager C
Overcrowding of hospitalcampus
Spread of disease Planned areas forhabitation
Allocate areas for use bypublic
Director of Nursing C
Staff dislocated fromfamily
Distress to staff Plan for accommodation Allocate staffaccommodation (work &living for staff)
Director of NursingNUM
Business managerC
Disease outbreak Infected persons Vaccines Plan for vaccines, factsheets
Public Health Unit C
Waste Disposal Vector Borne DiseaseInfections
Sprays for insects.Antiseptics
Assign contractors for pestcontrol
Public Health Unit C
Lack of Public Knowledge Suspicion - ConcernedPublic
Stockpile of HP Material Stockpile PH MaterialMedia person to duties
Director of NursingMHHSPublic Health Unit
C
Loss of ability to protectstaff and patients
Duress alarms
Fire alarms
Provide alternative alertsystem for nurses
Aim to have fire alarmscompliant
Provide alternative powersource for alarms
Purchase hand held audiblealarmsConsider purchase ofwhistlesCheck fire alarms
Ensure alarms areconnected to generator
Nursing staff
NUM
Engineering staffBusiness Manager
Manager Engineering
CWith appropriate
security
CWith appropriate
security
C
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COLLINSVILLE HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Ensure all staff have recentfire safety training
powerLiaise with Fire Department Director of Nursing
NUMBusiness manager
Insufficient staff Unable to provide safelevel of care in the eventof equipment failure
Unable to accesscomputerisedpathology/radiologyresults
Roster additional staff
Revert to manual process
Enter data when systemfixed
Calculate individual unitstaffing requirements
Identify human resourcesable to be on call andredeployed in the facilityAssess competence of oncall staffCourier to collect results
Develop means fornotification of lab & testresultsManual ordering tests
Ensure retrospective dataentry when computerservices resume
Director of NursingNurse Unit Manager
Business manager
Operational Staff
Nurse Unit Manager & Labstaff
Medical StaffNursing staffNursing staff
B
B
B
Air conditioning failure Unable to regulatetemperature andenvironment
Use alternate coolingdevices (eg.) Electrical ormanual fan
Refer to facility wide plan
Position fans for maximumbenefit
Identify patients requiringcoolingInform and educate staff
Nursing staff
Nursing staff
NUM/DON
B
B
Wall suction failure Wall suction notavailable
Use alternate suctiondevices
Assess need for and numberof portable suction unitsrequiredConsider co-locating suctiondependent patientsEnsure adequate supplyalternate drainage systemsReplace drain suction withmanual vacuum or drainage
NUM/DON
Nursing staffB
B
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COLLINSVILLE HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Provide emergencyoxygen/suction
bottlesEnsure small oxygencylinder with twin-o-vacsuction on resuscitationtrolleyEducate staff on use ofalternate devices
Nursing staff
Nurse Unit Manager
D
Unable to use ISTAT Bloods to path Develop policy for formallaboratory test
Medical staff C
Failure of 12 lead ECGmachine
Unable to diagnosepotential life-threateningconditions
Ensure access toemergency power
Use on battery power
Identify access toemergency power outlet
Keep batteries fully chargedon emergency powerIdentify location ofalternative ECG machinesInform and educate staff
Nurse Unit ManagerEngineering staff
Nursing staff
NUM/DON
D
DFailure of EmergencyAlarms
Unable to provide safeand secure environment
Increased staff vigilance
Refer to safety and securityplan.
Schedule regular patientroundsInform and educate Staff
Nursing staff
NUM/DONC
Failure of Patient callbuttons
Patients unable tosummon assistance
Refer to safety and securityplan.
More regular rounds ofpatients in the department.Inform and educate staff
NUM/DON C
Failure of InfusionPumps/Syringe Drivers
Staff unable to titratemedications and fluidsaccurately
Use on battery power ifavailableUse burettes
Consider alternateadministration routes.
Charge on generator powerif ableCharge batteries fullyEnsure adequate stockburettesProtocols for alternativeadministration
All staffNursing staff
Nursing staffMedical staff
C
C
CFailure of lifting devices Difficulties with lifting
heavy patients – manualhandling injuries
Identify alternate liftingdevices
Use hydraulic lifting devicesif availableUse of slide sheets, patslide,slida person etc.Ensure staff trained inmanual handling
All staff
All staff
NUM/DONBack care facilitator
C
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COLLINSVILLE HOSPITAL - GENERAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Pan room hopper Unable to clean bedpans / urinals adequately
Single patient use bedpans/urinals
Purchase sufficient forimmobile patientsRinse with “grey/waste”water and disinfect withchemical solutionInform staff of InfectionControl policy
NUM/DON
All staff
NUMInfection Control CNC
C
C
Page - 141 28/08/2013
Business Continuity PlanCollinsville Hospital – Utilities Services
COLLINSVILLE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Loss of LPG supply
Unable to providecooking facilities
Unable to provide hotwater
Secure LPG site andimplement retrieval/disposalof hazardous materialArrange urgent supply ofportable LPG cylinders
Use alternate energysource Gas Cook top orBBQHeat water with alternateenergy source Gas Quickheat water heater.Wash / clean with coldwater
Dishwasher heats ownwaterStaff Education
Engineer to establishsecurity of the site and riskassess immediate needs.Identify number of cylindersrequired and allocate as perpriority listingArrange for supplier to fillstorage tanks if notdamagedIdentify alternate energysources for cooking
Identify alternate energysources for water heating
Identify cleaning processesthat can use cold water oruse disposable ware
Identify alternate washingregime for patient hygieneNo remedial action required
Educate staff oncontingency plans
DON/BM/Engineering
DON/BM/Engineering
DON/BM/Engineering
Business manager
Manager Engineering
DON/BM/EngineeringBusiness ManagerNUM/DON
Business Manager/Cook
A
A
A
A
B
B
Oxygen supply disrupted Use cylinder oxygen Ensure adequate supplies Operational Officers/ BusinessManager
A
Inability to supply mainspower to facilities
Emergency powergeneration
Identify existing supply ofemergency powergenerationRefer to power points/outlets with emergencygeneration in each area
DON/BM/Engineering
DON/BM/Engineering
Nurse Unit Manager
A
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COLLINSVILLE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Ration use of emergencypowerUse alternate powersourcesSupply additional lighting
Discharge/ relocate patientswithin facility
Confirm essential equipmentonly connected to generatorpower outletsEnsure essential lights andequipment supplied.Consider need to purchaseextension leadsDevelop a procedure for useof emergency power in eacharea and inform staffContactEngineering/Contractor toensure adequate fuel sourcefor use of generatorEnsure fuel storagestandards are maintainedIdentify generator loadcapacityFully charge batteries on allessential equipmentLocate/purchase torches/lanterns and batteriesInform and educate staff
Manager Engineering
NUM/DON
NUM/DON
DON/BM/Engineering
DON/BM/Engineering
Nurse Unit Manager
Nurse Unit Manager
All Managers
A
A
A
A
A
A
Consider activation ofMHHS Disaster PlanClose Facility
Staff Education
Consult current MHHSDisaster Plan for processLiaise with alternativeservice provider for care ofpatientsTransfer patients out & closefacilityEducate staff oncontingency arrangements
MHHS Manager
MHHS ManagerMedical Superintendent
MHHS Manager only
Nurse Unit Manager
A
A
Loss of water supply forgeneral use, e.g., toilets,patient hygiene
Liaise with LocalCouncil Authority resupplies of water.
Ration water usage
Identify alternative watersources
Rationalise services anddevelop plan for waterrestrictionSource / cost alternatesupplies, e.g. / Watertankers / Fire service supply
MHHS ExecutiveDON/BM/Engineering
A
Page - 143 28/08/2013
COLLINSVILLE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Loss of drinking water
Contingency Failure
Identify alternative suppliesof drinking water
Discharge/ relocate patientswithin facility
Consider activation ofMHHS Disaster PlanUse emergency supply
Close facility
Staff education
Initiate use of alternatesupplyConsider purchase of bottledwaterLiaise with Renal DialysisUnit to save empty dialysatecontainers for water storageBuy containers for storage ofdrinkable waterIdentify patients fordischarge or relocationConsult current MHHSDisaster Plan for processLiaise with local council /utilities re emergency watersupplyLiaise with alternativeservice provider for care ofpatientTransfer patients out andclose facilityEducate staff oncontingency
DON/BM/Engineering
MHHS ExecutiveManager Stores
Business Manager
Medical Superintendent
MHHS Manager
MHHS Manager
MHHS Manager / MedicalSuperintendent
A
A
A
A
Sewerage Unable to dispose ofwaste products due towater failure
Ensure facility wide plan Develop facility plan forwaste disposal
MHHS Executive D
Ensure Local council andPublic Health Unitinvolvement.
Utilise “grey/used” water
Designate toilets to be used
Alternate toilet facilities
Single patient use bedpans/
Inform staff to save waterafter patient hygienePlace bucket for used waterin each toilet cubicle forflushing purposesClose off toilets not for useand post signsIdentify alternate toiletdevices e.g., porta loos, andnumber requiredSource supply / cost ofalternate devicesPurchase sufficient for
Nurse Unit Manager
Operational Services
Nurse Unit Manager
NUM/BM/DON/Engineering
DON/BM/Engineering
Nurse Unit Manager
D
D
D
D
Page - 144 28/08/2013
COLLINSVILLE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Failure of contingency
urinals
Discharge/ relocate patientswithin facilityConsider activation ofMHHS Disaster Plan
Close facility
Staff education
immobile patientsRinse with “grey/waste”water and chemical solutionInform staff of InfectionControl policyIdentify patients fordischarge or relocationConsult current MHHSDisaster Plan for processLiaise with local council /utilities re emergency watersupplyArrange for septic tankpumping truck to pumpsewerage out of hospitalpipesLiaise with alternativeservice provider for care ofpatientTransfer patients out, closefacilityEducate staff oncontingency plans
All staff
Medical Superintendent
MHHS ManagerManager Engineering
DON/BM/Engineering
Medical Superintendent
NUM/DON/Managers
D
D
D
Power failure Mains power notavailable. Generatorsupplies emergencypower
Refer to mains powerfailure plan
Inform and educate staff DON/NUMBM/Engineering B
Lighting failure Difficulties in patientobservation and care.
Increased risk forpatients and staff
Utilise emergency lighting
Maximise natural lighting
Utilise alternate lighting
Maintain WH&Sprecautions
Identify provision foremergency lightingRelocate immobile patientsto best lit areasClean and maintain windowsand fittingsEnsure blinds/curtains openEnsure adequate supplytorches / battery operatedlights and batteriesClear patient areas, workareas and corridors of all
Engineering staff
Nursing staff
Operational Staff
All staffNurse Unit Manager
NUM/DON/BM/ All staff
B
B
Page - 145 28/08/2013
COLLINSVILLE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
No safety/evacuationlighting available
Provide additional portablelighting
hazardsIdentify and sourcealternative lightingStaff member to placelighting in strategic areas forsafetyIssue clinical staff withtorches
NUM/DON /All staff
Page - 146 28/08/2013
Business Continuity Plan
Dysart Hospital – Clinical & General
DYSART HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?
HBCISAccess Failure
Unable to registerpatients
No patient ID labels
Manual registration
Manual Process
Adequate supply downtime forms
Hand write requests
Ensure blank details are recorded inchart
Administration Staff
Administration Staff
Administration Staff
B
HBCISEmergency DepartmentModule failure
Unable to utiliseTRIAGE treatment,admission anddischarge
Unable to recordstatisticalrequirements
Manual recording.
No written record of UR Numbersmaintained on site
Retrospective data entry
Ensure correct details are recorded inthe chart
Check and update missing data
Nursing Staff
Administration StaffNursing staff
C
Printing services Failure
Unable to printresults/labels
Manual recording of labels
Results can be obtained via phone orinternet
Ensure adequate staffing to coverworkloadList of relevant phone numbers e.g.pathology, x-ray etc.
Business ManagerAdministration StaffNursing Staff
B
Computer failure
Unable to generateID labels, trackpatient location,bed status, labresults, emails,online policies andprocedures
Record patient details manually Ensure supply of HBCIS downtimeformsPre-print labels on existing patientsHand write on blank labels for newadmissionsUpdate patient location and bedstatus at regular intervals
Administration StaffNursing staff
B
Page - 147 28/08/2013
DYSART HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?
Unable to trackpatient location andbed statusUnable to providepatient dietaryrequirements
Revert to manual process Update patient diet lists and haveavailable for collection by cateringservices
Nursing StaffOperational Stream
C
Telephone Failure
No internal orexternalcommunications
Refer to facility wide telecommunicationsplan
Inform and Educate staffNUMRegistered NurseBusiness ManagerDON
C
FAX Failure
Unable to receiveor send patientinformation
Utilise alternate lines of communicationSend patient information by courier,registered post or scan and email
Delay transfer of information untilservices resumed
NUMAdministration StaffDON
B
B
Photocopy Failure
Unable to copy,scan or faxdocuments
Utilise alternate lines of communication Telephone CommunicationUtilise photocopier at Private SurgerySend original documents with thepatient in chart
Delay transfer of information untilservices resumed
All Staff
A
Oxygen Supply Disrupted
Piped oxygenfailure
Use oxygen cylinders Ensure adequate supply of cylinders
Ensure all staff educated in cylinderchangeoverConsider co-locating high oxygenusers
Operational StreamAdministrationNursing
All Staff
B
Wall suction failure Wall suction notavailable
Use alternate suction devices
Provide emergency oxygen/suction
Assess need for and number ofportable suction units requiredConsider co-locating suctiondependent patientsEnsure adequate supply alternatedrainage systemsReplace drain suction with manualvacuum or drainage bottles
NUMDONNursing Staff
BLimited supply in
hospital
Page - 148 28/08/2013
DYSART HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?Ensure small oxygen cylinder withtwin-o-vac suction on resuscitationtrolley
Failure of Welsh Allenthermometer
Potential forinaccuracy oftemperaturereadings
Use digital thermometer Ensure stock digital thermometers NUMDONNursing Staff
C
Failure of non-invasiveblood pressure (NIBP)monitors
Unable toelectronicallymeasure bloodpressurerecordings
Use manual sphygmomanometer Ensure adequate number of manualsphygmomanometers NUM
DONNursing Staff
C
Failure of Glucometer
Potential fordecreasedaccuracy in bloodglucose readings
Change battery in Glucometer
Formal laboratory blood glucose analysisfor abnormal results
Ensure adequate supply of batteriesand test strips
Inform and educate staffDevelop policy for formal laboratorytest
NUMDONNursing Staff
C
A
Failure of 12 lead ECGmachine
Unable to diagnosepotential life-threateningconditions
Ensure access to emergency power oraccess battery backupUse on battery power
Identify access to emergency poweroutlet
Keep batteries fully charged onemergency powerIdentify location of alternative ECGmachinesInform and educate staff
NUMDONNursing Staff
A
limited battery life
Failure of Pulse oximeters Unable todetermine oxygensaturation
Increase nursing observationEducate staff re basic physicalassessment of patient
NUM / DONNursing Staff C
Defibrillator malfunction Unable todefibrillate patients
Have compliant defibrillator available
Connect to emergency power
Use battery backup
Identify non compliant equipmentAim to replace non compliantequipmentIdentify & re allocate compliantdefibrillatorQAS on standbyInform & Educate staffIdentify existing emergency poweroutletsHave batteries fully charged
NUMDONNursing Staff
A
Page - 149 28/08/2013
DYSART HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?Medical equipment failure Unable to provide
specialised medicalequipment
Ventilators
Blood warmers
Biers machine
Level 1 transfuser
Spirometer
Slit lamp
Plaster saw
Utilise emergency powerManual process
Battery back-up if available
Manual ventilation
Use alternate equipment
Manual process
Manual process
Manual process
Check existing emergency poweroutletsUse black bag closed circuit with100% oxygenFully charge batteries
Use alternate oxygen driven ventilatorEnsure adequate staff available formanual ventilationEnsure equipment is available
Warm water bath
Double cuff tourniquet
Blood pumping set and pressure bag
Use peak flow meters
Perform visual examinationTreat prophylacticallyRefer to ophthalmologist
Use plaster cuttersApply a back slab
NUMDONNursing Staff
C
C
A
A
C
C
Unable to use ISTAT Bloods to path Develop policy for formal laboratorytest
NUMDONNursing Staff
C
Failure of EmergencyAlarms
Unable to providesafe and secureenvironment
Increased staff vigilance
Refer to safety and security plan
Schedule regular patient rounds
Direct notification via phone to switchor runner to contact fire services,security, policeInform and educate Staff
All staff
BCan function but
time consuming andcan lead to
decreased patientsafety
BFailure of Patient callbuttons
Patients unable tosummonassistance
Refer to safety and security plan. Use of hand bellsInform and educate staff
NUMDONBusiness ManagerNursing Staff
C
Page - 150 28/08/2013
DYSART HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?
Refrigeration Vaccine
Drugs and medicalsupplies requiringrefrigeration maybecome unstable
Place drugs in refrigerators which areconnected to emergency power supply
Use eskies and ice
Review emergency power outlets andmanage vaccines as per infectioncontrol guidelines
Monitor refrigerator temperature withthermometerUtilise SBVP EskyInform & Educate staff
DONNUMNursing StaffChild & CommunityHealth Staff
A
Failure of InfusionPumps/Syringe Drivers
Staff unable totitrate medicationsand fluidsaccurately
Use on battery power if available .
Use burettesConsider alternate administration routes
Charge on generator power if ableCharge batteries fully
Ensure adequate stock burettesProtocols for alternativeadministration
NUMDONNursing Staff
ABatteries can last up
to 12 hours.
Failure of SequentialCompression Devices
Potential increasedrisk of DVT/Embolus
Use alternative methods of deterringthrombo-embolus
Identify at risk patients
Consider compression stockings/drug therapyDevelop policyEnsure adequate supplies ofstockings
NUMDONNursing Staff
C
Failure of lifting devices Difficulties withlifting heavypatients – manualhandling injuries
Access Battery back up of lifting devices Use hydraulic lifting devices ifavailableUse of ski sheets, bed sheets, hovermattress etc.Ensure staff trained in manualhandling
NUMDONNursing StaffNurse EducatorWH&S Officer
B
Failure of Video/TV Negative impact onpatient education /enjoyment
Verbal education
Alternative recreational facilities
Develop alternate educationpackages for patients
Prepare mobile library
NUMDONBusiness Manager
C
Staffing Increased manualtasks may influenceworkload
Roster extra staff on dutyPlace staff "on call"
Estimate staffing numbers requiredfor 24 hour periodPrepare rosters
NUMDONBusiness Manager
B
Telehealth Unable toguarantee liaisonwith Specialist
Source alternative conferencing unitCommunicate by telephoneInternet e.g. Skype etc.Mobile video calling
Communicate with ITEnsure availability of telephone,laptopEducate staff
NUMDONBusiness Manager
C
Page - 151 28/08/2013
DYSART HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?Equipment Function Unable to
guaranteeequipmentaccuracy
Check all equipment for functionality assoon as possible after disruption of power
Identify all equipment to be checked NUMDONBusiness ManagerNursing Staff
C
Failure of Dishwasher
Refer to FoodSafety Plan
Use Disposables Ensure adequate supply ofdisposables
CookOperational StreamBusiness ManagerDON
C
B
Loss of communicationwith pre Hospital transferservices and referralcentres
Unable tocommunicate withQAS
Unable tocommunicate withGP’s
Use alternate communication channels
Develop an alternate referral dischargeprocess
Consider the use of Mobile Phone ifnetwork is operationalUse 2 way radioDevelop criteria for referral based onavailable services
Develop pro forma for requiredpatient information
NUMDONNursing StaffBusiness Manager
C
Failure of EFTPOS fuelcard service
Unable to obtainfuel
Arrange credit facility Liaise with local fuel distributor forcredit facilities for fleet vehicles /Generator fuel
DONBusiness Manager
C
Unable to transportsupplies from/to facility
Unable to receiveSupplies
Use alternate methods for transport ofsupplies
Identify and engage externalcontractors
NUMDONBusiness Manager
C
Overcrowding of hospitalcampus
Spread of disease Planned areas for habitation Allocate areas for use by public NUMDONNursing StaffBusiness Manager
C
Staff dislocated fromfamily
Distress to staff Plan for accommodation Allocate staff accommodation (work &living for staff)
NUMDONNursing StaffBusiness Manager
C
Page - 152 28/08/2013
DYSART HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?Disease outbreak Infected persons Vaccines Plan for vaccines, fact sheets Public Health Unit
Child HealthNursesDONNUMBusiness Manager
C
Waste Disposal Vector BorneDisease Infections
Sprays for insects.Antiseptics
Assign contractors for pest control Public Health UnitBusiness ManagerDON
C
Page - 153 28/08/2013
Business Continuity PlanDysart Hospital – Utilities Services
DYSART HOSPITAL - UTILITIESA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long canyou functionwithout thisservice?
Loss of LPGsupply
Unable to provide cookingfacilities
Unable to provide hotwater
Unable to utilise drier inlaundry
Secure LPG site and implementretrieval/disposal of hazardousmaterialArrange urgent supply ofportable LPG cylinders
Use alternate energy sourcee.g. Gas Cook top or BBQ
Wash / clean with cold water
Dishwasher heats own water
Utilise drier in staff quartersClothes line adequate to hangwashingOut source laundry – e.g.Moranbah Hospital, PrivateLaundry
Staff Education
Engineer to establish security of the site andrisk assess immediate needs.Arrange for supplier to fill storage tanks ifnot damagedIdentify alternate energy sources for cooking
Identify alternate energy sources for waterheatingIdentify cleaning processes that can usecold water or use disposable wareIdentify alternate washing regime for patienthygiene.
No remedial action required
Clothes trolley baskets and pegs availableWorkload Management
Educate staff on contingency plans
Manager EngineeringBusiness ManagerDONOperational Stream
C
B
B
Inability tosupply mainspower tofacilities
Emergency power generation Identify existing supply of emergency powergeneration
Refer to power points/ outlets withemergency generation in each areaConfirm essential equipment only connectedto generator power outlets
A
Page - 154 28/08/2013
DYSART HOSPITAL - UTILITIESA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long canyou functionwithout thisservice?
Ration use of emergency powerUse alternate power sources
Supply additional lighting
Discharge/ relocate patientswithin facility
Consider activation of MHHSDisaster Plan
Close FacilityStaff Education
Ensure essential lights and equipmentsupplied.Consider need to purchase extension leadsDevelop a procedure for use of emergencypower in each area and inform staffEnsure adequate fuel for generator useEnsure fuel storage standards aremaintainedIdentify generator load capacity
Fully charge batteries on all essentialequipmentLocate/purchase torches/ lanterns andbatteriesUse natural lighting -open windows anddoorsIdentify patients for discharge or relocationConsult current MHHS Disaster Plan forprocessLiaise with alternative service provider forcare of patients
Transfer patients out & close facilityEducate staff on contingency arrangements
Manager EngineeringDirector of Rural ServicesDONNUMBusiness ManagerAll Staff
A
A
Loss of watersupply forgeneral use,e.g., toilets,patienthygiene
Loss of drinking water
Contingency Failure
Ration water usage
Identify alternative water sources
Identify alternative supplies ofdrinking water
Discharge/ relocate patientswithin facilityConsider activation of MHHS
Rationalise services and develop plan forwater restriction
Source / cost alternate supplies, e.g. / Watertankers / Fire service supplyInitiate use of alternate supply
Consider purchase of bottled water
Identify patients for discharge or relocation
Consult current MHHS Disaster Plan for
Manager EngineeringDirector of Rural ServicesDONNUMBusiness ManagerAll Staff
A
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DYSART HOSPITAL - UTILITIESA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long canyou functionwithout thisservice?
Disaster Plan
Local Emergency Water Supply
Close facility
Staff education
process
Liaise with local council / utilities reemergency water supplyLiaise with alternative service provider forcare of patientTransfer patients out and close facility
Educate staff on contingency
Sewerage
Unable to dispose ofwaste products due towater failure
Ensure facility wide plan Develop facility plan for waste disposal Manager EngineeringDirector of Rural ServicesDONBusiness Manager
D
Ensure LocalCouncil andPublic HealthUnitinvolvement. Failure of contingency
Designate toilets to be used
Source supply / cost of alternatedevices e.g. porta loos
Single patient use bedpans/urinals
Discharge/ relocate patientswithin facility
Consider activation of MHHSDisaster Planfacility
Staff education
Place bucket for used water in each toiletcubicle for flushing purposesClose off toilets not for use and post signs
Identify alternate toilet devices e.g., portaloos, and number required
Purchase sufficient for immobile patientsInform staff of Infection Control policy
Identify patients for discharge or relocationConsult current MHHS Disaster Plan forprocessLiaise with local council / utilities reemergency water supply
Arrange for septic tank pumping truck topump sewerage out of hospital pipes
Liaise with alternative service provider forcare of patientTransfer patients outClose facility
Educate staff on contingency plans
Manager EngineeringDirector of Rural ServicesDONNUMBusiness ManagerAll Staff
D
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DYSART HOSPITAL - UTILITIESA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long canyou functionwithout thisservice?
Power failure
Mains power notavailable. Generatorsupplies emergencypower
Refer to mains power failure plan Inform and educate staff Manager EngineeringDirector of Rural ServicesDONNUMBusiness ManagerAll Staff
A
Lightingfailure
Difficulties in patientobservation and care
Increased risk for patientsand staff
No safety/evacuationlighting available
Utilise emergency lighting
Maximise natural lighting
Utilise alternate lighting
Maintain WH&S precautions
Provide additional portablelighting
Identify provision for emergency lightingRelocate immobile patients to best lit areas
Clean and maintain windows and fittingsEnsure blinds/curtains open
Ensure adequate supply torches / batteryoperated lights and batteries
Clear patient areas, work areas andcorridors of all hazards
Identify and source alternative lightingStaff member to place lighting in strategicareas for safetyIssue clinical staff with torches
DONNUMBusiness ManagerAll Staff
B
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Business Continuity Plan
Moranbah Hospital
MORANBAH HOSPITAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Computer failure Unable to generate IDlabels
Unable to track patientprogress notes location
Unable to accesscomputerisedpathology/radiologyresults
Record patient detailsmanually
Revert to manualprocess
Revert to manualprocess
Enter data when systemfixed
Ensure supply of HBCIS downtimeformsPre –print labels on existing patientsHand write on blank labels for newadmissionsUpdate patient location and bedstatus at regular intervalsNotify after-hours On-Call of allpatient movementsDevelop a process for disseminatingpatient updates as part of the facilitycommunication planEnsure supply of pathology resultforms
Develop means for notification of lab& test resultsManual ordering testsEnsure retrospective data entry whencomputer services resumeBackup any non centralised data orward specific computer programs
Administrative and nursingstaff
Nursing Staff Team Leader
Administrative and Nursingstaff
Nurse Unit Manager
Nurse Unit Manager / CN
Administrative staff
CCan function but very
time consuming
C
C
C
C
Power failure Mains power not available Generator poweravailable
Inform and educate staff Nurse Unit Manager /DON BCan function in most
areas.
Lighting failure Difficulties in patientobservation and care
Utilise emergencygenerator lighting
Maximise naturallighting
Utilise alternate lighting
Identify provision for emergencylightingRelocate immobile patients to best litareasClean and maintain windows andfittingsEnsure blinds/curtains openEnsure adequate supply torches /battery operated lights and batteries
Identify provision foremergency lightingEngineering staffNursing staffCleaning staff
All staffNurse Unit Manager / DON
BCan function in most
areas.
Page - 158 28/08/2013
MORANBAH HOSPITAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Increased risk for patientsand staff
Maintain WH&SprecautionsGenerator poweravailable
Clear patient areas, work areas andcorridors of all hazardsEducate staff
Nurse Unit Manager /All staff
Air conditioning failure Regulate temperature andenvironment withGenerator power
Use alternate coolingdevices and turn offunnecessary air-consElectrical or manual fan
Position fans for maximum benefit
Identify patients requiring cooling
Nursing staff AEspecially in summer
Limited where nowindow.
Telephone failure No internal / externaltelephonecommunications .
Refer to facility widetelecommunicationsplan
Inform and educate staff Nurse Unit Manager /ShiftTeam Leader /DON
AOnly for a limited time.
Wall oxygen supplyfailure
Wall oxygen not available Use cylinder oxygen Identify anticipated requirements ofcylinder oxygen for ward patientsOrder extra required cylindersEnsure all oxygen cylinders fullEnsure corresponding number ofoxygen fittings available at wardlevel.Ensure all staff educated in cylinderchangeover.
Nurse Unit Manager / CN
B
Wall suctionfailure
Wall suction notavailable
Use alternate suctiondevices
Provide emergencyoxygen/suction
Assess need for and number ofportable suction units requiredConsider co-locating suctiondependent patientsEnsure adequate supply alternatedrainage systemsReplace drain suction with manualvacuum or drainage bottles
Ensure small oxygen cylinder withtwin-o-vac suction on resuscitationtrolley
Nurse Unit Manager
Nursing staffMedical staff
B
BLimited supply in
hospital
Digital scales fail Unable to record weight Use alternative scales Use bathroom scales
Use weighted scales if availableNurse Unit Manager
C
Failure of WelshAllenthermometer
Potential for inaccuracyof temperature readings
Use digitalthermometer
Ensure stock digitalthermometers
Nurse Unit ManagerC
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MORANBAH HOSPITAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Failure of non-invasive bloodpressure (NIBP)monitors
Unable to electronicallymeasure bloodpressure recordings
Use manualsphygmomanometer
Ensure adequate number ofmanual sphygmomanometers
Nurse Unit ManagerC
Failure ofGlucometer
Potential for decreasedaccuracy in bloodglucose readings
Change battery inGlucometer
Formal laboratoryblood glucoseanalysis for abnormalresults
Ensure adequate supply ofbatteries and test strips
Inform and educate staffDevelop policy for formallaboratory test
Nursing staff /Unit Manager
Nursing staff
C
A.A potential treatment
problem
Failure of 12 leadECG machine
Unable to diagnosepotential life-threatening conditions
Ensure access toemergency power oraccess batterybackupUse on battery power
Identify access to emergencypower outlet
Keep batteries fully charged onemergency powerIdentify location of alternativeECG machinesInform and educate staff
Nurse Unit Manager / DON
Nurse Unit Manager /NursingStaff
Nurse Unit Manager
ANo problem if
emergency powerpoint kept for use.
Alimited battery life
Failure of Pulseoximeters
Unable to determineoxygen saturation
Increase nursingobservation
Educate staff re basic physicalassessment of patient
Nurse Unit Manager CStaff trained in physical
assessment
Failure ofEmergencyAlarms
Unable to provide safeand secureenvironment
Increased staffvigilance
Refer to safety andsecurity plan
Schedule regular patient rounds
Direct notification via phone toswitch or runner to contact fireservices, security, policeInform and educate Staff
Nursing staff
All staff
BCan function but time
consuming and can leadto decreased patient
safety
B
Failure of Patientcall buttons
Patients unable tosummon assistance
Refer to safety andsecurity plan.
Inform and educate staff Nurse Unit ManagerC
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MORANBAH HOSPITAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Failure of InfusionPumps/SyringeDrivers
Staff unable to titratemedications and fluidsaccurately
Use on battery powerif available.
Use burettesConsider alternateadministration routes
Charge on generator power ifable Charge batteries fully
Ensure adequate stock burettesProtocols for alternativeadministration
Nursing Staff
ABatteries can last up
to 12 hours.
Failure ofSequentialCompressionDevices
Potential increased riskof DVT /Embolus
Use alternativemethods of deterringthrombo-embolus
Identify at risk patients
Consider compression stockings/drug therapyDevelop policyEnsure adequate supplies ofstockings
Unit Manager Medical staff
Unit Manager /Medical Staff
Nursing staff
C
Refrigeration Drugs and medicalsupplies requiringrefrigeration maybecome unusable
Place drugs inrefrigerators whichare connected toemergency powersupply - as per ColdChain Protocol
Use Eskies withportable thermometersand ice as per ColdChain Protocol
Review emergency power outlets
Monitor refrigerator temperature withthermometerConsider purchase of eskies andsupply of ice
Unit Manager / DON
Nursing staff
Nurse Unit Manager / CN
A
Awith eskies
Failure of lifting devices Difficulties with liftingheavy patients – manualhandling injuries
Access Battery back upof lifting devices
Use hydraulic lifting devices ifavailableUse of ski sheets, bed sheets, etc.Ensure staff trained in manualhandling
All staff
Unit ManagerWH&S Officer
B
Pan room hopper Unable to clean bed pans/ urinals adequately
Single patient usebedpans/ urinals
Purchase sufficient for immobilepatientsRinse with “grey/waste” water anddisinfect with chemical solutionInform staff of Infection Control policy
Unit Manager / DON
Nurse Unit ManagerNB “Hopper” has been
replaced with“Macerator” and
disposable urinals &bed pans
Page - 161 28/08/2013
MORANBAH HOSPITAL
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Failure of Video/TV Negative impact onpatient education /enjoyment
Verbal education
Alternative recreationalfacilities
Develop alternate educationpackages for patients
Prepare mobile library
Nurse Unit Manager
Volunteers
CCan still operate
Failure of Fax Unable to receive or sendpatient information
Utilise alternate lines ofcommunication
Send patient information byrunner/courierDelay transfer of information untilservices resumed.
Unit Manager /BusinessManagerMedical staffAdmin. staff
ACan still operate but
time consuming
Failure of Copier Unable to copydocuments
Utilise alternate lines ofcommunication
Telephone information
Send original documents with patientand document in chartDelay transfer of information untilservices resumed
Nursing staffMedical staff
C
B
Staffing Increased manual tasksmay influence workload
Roster extra staff ondutyPlace staff "on call"
Estimate staffing numbers requiredfor 24 hour periodPrepare rosters
Nurse Unit Manager / DONB
Equipment Function Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon aspossible after disruptionof power
Identify all equipment to be checked Nurse Unit Manager/ DON
Page - 162 28/08/2013
Business Continuity PlanProserpine Hospital – General & Clinical Services
PROSERPINE HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?Ensure all records in file • Notify all MO’s/ward/depts to return
outstanding recordsManager ofSupport Services B
Run location by location for charts notreturned.
Manager to arrange approp staff tocomplete task.
Manager ofSupport Services
Failure HBCIS MedicalRecords & TrackingSystem
Unable to locate &send medicalrecords
Use manual tracing system Implement manual system (eg)tracer cardsUpdate system with changes & newregistrations
Manager ofSupport Services
Admin staff
Failure of HBCIS PatientMaster Index (PMI
Cannot allocatenew UR Numbers
Manual allocation of URN’s Check backup PMI file is up to date. Manager ofSupport Services
BCannot search forexisting URN’s
Use backup PMI to look up existingURN’s
• Manually allocate & look up URN’s
Update system
Administrative staff
Manual process • Print hard copy of PMI prior tocritical date
Manager ofSupport Services
Prepare a block of unissued downtime URnumbers
• Allocate downtime UR numbers Manager ofSupport Services
Failure HBCIS Admission,Transfer, Discharge (ADT)
Cannot search ADTto track patients
Not critical, wait until system returns • Update System Manager ofSupport Services
BCannot run enquiryreports
Keep hard copy list in Medical RecordsDepartment.
• Have register and down formsavailable. Update patient list asneeded.
Admin Staff
HBCIS AppointmentScheduling
Unable to printreports for patients
to attend clinics
Print reports one week in advance wherepossible.
Manual list of attendees. Business Manager
ANo access to activity data Unable to access
reports.Access when system returns Retrospective updating of data. Business Manager C
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PROSERPINE HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?No access to pathology /radiology results
Unable to accesscomputerisedpathology/radiologyresults
Revert to manual process Ensure retrospective data entry whencomputer services resume
DON & FM /Business Managers
B
Unable to fax dischargesummaries.
Increased requestsfrom GP for followup dischargeinformation.
Hand write discharge summaries. Givepatients a copy on discharge.
Post copy handwritten dischargesummaries to General Practitioners.
Administrative staff C
Flooding of Medical recordDepartment.
Destruction ofcharts
Move charts if possible to safe area. Rollsof black plastic and tape to secure.
Arrange for staffing to move charts.Or Cover filings bays with plastic andsecure.
Manager ofSupport Services
C
EDIS failure Inability to recordemergencypresentations
manual recording adequate supply of downtime formsand triage forms
NUM, admin staff C
Computer failure unable to printresults / labels etc
manual recording of patient details andresults.
ensure supply of downtime forms andmanually record information.
admin, nursing andmedical staff
C
FAX Failure unable to send orreceive patientinformation
utilise alternate communication lines ordelay transfer of information
Inform and educate staff. Delaytransfer of information or alternatemeans of communications
NUM / BM B
BMDF Failure unable to copy orscan documents
utilise alternate communication lines ordelay transfer of information
Telephone information. Send originaldocuments with patient anddocument in chart. Delay ofinformation until restored
Nursing / medicaland admin staff
Oxygen Supply Disrupted oxygen notavailable
use cylinder oxygen Ensure adequate supplies. Ensurestaff education on use. Consider co-locating high oxygen users.
NUM, nursing staff,operational staff
B
Failure ofRefrigeration/Cool Rooms
food spoilage referto food safety plan
Essential fridges on emergency power.Source food offsite if needed. Considerlong life options
Access Emergency power. Developplan for preparation and transport offood from other sources. Purchasedry / tinned food. Consider long lifemilk and bottled water if needed
operationalservices managerand BM
B
Failure of Dishwasher refer to food safetyplan
use disposables adequate supplies needed operationalservices managerand BM
C
Page - 164 28/08/2013
PROSERPINE HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?
Ensure one compliant transportmonitor available in central location
Schedule tests prior to critical dates
Nurse UnitManager
DTransport monitorsmalfunction
Unable to monitorcritically ill orunstable cardiacpatients in transit
Aim to have at least one complianttransport monitor or list of compliantmachines.Assess patients prior to critical dates.
Assess pt need for transportCharge batteries
Medical staffNursing staff
C
Defibrillator malfunction Unable todefibrillate patients
Have compliant defibrillator available
Connect to emergency power
Use battery backup
Identify non compliant equipmentAim to replace non compliantequipmentIdentify & re-allocate compliantdefibrillatorInform & educate staffIdentify existing emergency poweroutletsHave batteries fully charged
Nurse UnitManager
D
Medical equipment failure Unable to providespecialised medicalequipment
Bi-PAP/CPAP
Ventilators
Blood warmers
Slit lamp
Plaster saw
Utilise emergency power
Manual processBattery back-up if availableManual ventilation
Manual process
Manual process
Manual process
Check existing emergency poweroutlets
Fully charge batteriesEnsure adequate staff available formanual ventilation
Warm water bath
Perform visual examination
Treat prophylacticallyRefer to ophthalmologist
Apply a back slab / plastic cutters
Nurse UnitManager
Nursing staff
Medical staff
A
C
C
Page - 165 28/08/2013
PROSERPINE HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?Failure of Monitorsincluding cardiac &oximetry
Unable to identifyarrhythmias /oxygen saturation
Use of emergency power
Use battery backup
Increased nursing & medical observation
Check existing emergency poweroutletsIdentify non compliant equipmentAim to replace non complaintequipmentIdentify & position compliant monitorsensuring access to emergency powerEnsure adequate supply of batteries.Have batteries fully charged.Identify & ensure adequate medical &nursing staff coveragePrioritise patients for monitoringInform and educate staff’
Nurse UnitManager
Nurse UnitManager
Nursing staff
D
D
C
Pathology servicesnot available
Identify and rationalise use of availablevehicles
Develop a plan for centralisingvehicles
DON & FM /Medical Staff
CUnable to providetransport services
Discontinue non-essential services Prioritise useNotify clients of potential fordisruption to normal servicesRe-admit at risk patients if necessary
Business manager C
Overcrowding of hospitalcampus
Spread of disease Planned areas for habitation Allocate areas for use by public DON & FM C
Staff dislocated fromfamily
Distress to staff Plan for accommodation Allocate staff accommodation (work &living for staff)
DON/NUM/BM C
Disease outbreak Infected persons Vaccines Plan for vaccines, fact sheets DON/MBH/AHS/TPHU
C
Lack of Public Knowledge Suspicion -Concerned Public
Stockpile of HP Material Stockpile PH MaterialMedia person to duties
BM/NUM/DON/TPHU
C
Insufficient staff Unable to providesafe level of care inthe event ofequipment failure
Roster additional staff Calculate individual unit staffingrequirements
All Line Managers B
Identify human resources able to beon call and redeployed in the facility
Director Of Nursing B
Page - 166 28/08/2013
PROSERPINE HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?
Assess competence of on call staff Nurse UnitManager
B
Wall suction notavailable
Use alternate suction devices Assess need for and number ofportable suction units required
NUMWall suction failure
Provide emergency oxygen/suction Consider co-locating suctiondependent patientsEnsure adequate supply alternatedrainage systemsReplace drain suction with manualvacuum or drainage bottlesEnsure small oxygen cylinder withtwin-o-vac suction on resuscitationtrolleyEducate staff on use of alternatedevices
Nursing staff
B
Unable to use ISTAT Unable to diagnosepotential life-threateningconditions
Ensure access to emergency power Identify access to emergency poweroutlet
Nurse UnitManager /Engineering staff
D
Failure of 12 lead ECGMachine
Unable to providesafe and secureenvironment
Use on battery power
Increased staff vigilance
Keep batteries fully charged onemergency power
Inform and educate staffSchedule regular patient rounds
Nurse UnitManager/ Nursingstaff
D
Failure of EmergencyAlarms
Patients unable tosummonassistance
Utilise bells with capable patients Inform and educate Staff and Patients Nurse UnitManager
B
Failure of Patient callbuttons
Patients unable tosummonassistance
Refer to safety and security plan. More regular rounds of patients in thedepartment. Inform and educate staffand patients
Nurse UnitManager
B
Use on battery power if available . Charge on generator power if ableCharge batteries fully
All staff Nursingstaff
Ensure adequate stock burettes
Use burettes Protocols for alternativeadministrationUse hydraulic lifting devices ifavailable
Failure of InfusionPumps/Syringe Drivers
Staff unable totitrate medicationsand fluidsaccurately
Consider alternate administration routes.
C
Page - 167 28/08/2013
PROSERPINE HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?Failure of lifting devices Difficulties with
lifting heavypatients – manualhandling injuries
Identify alternate lifting devices Use of slide sheets, pat slide,slidaperson etc.
All staff C
Macerators Unable to disposeof used pans andurinals
Utilise supply of washable pans andurinals. Manual Cleaning
Scrub and/or soak. Encourage use oftoilet as much as possible.
All clinical staff B
Failure of Blood /immunisation Fridges
Unable to preserveintegrity of blood.
Transfer blood and immunisations storeselsewhere
Investigate alternative storagesolutions.
NUM B
Spoilage ofpharmaceuticalsrequiringrefrigeration /freezing
Ensure fridges and freezers connected toemergency power
Check access to emergencygenerator power
Pharmacist within 30 minutes
Ensure fridges monitored for temperature Ensure On call pharmacist roster torespond to fridge/freezer failure alarm
Pharmacist /nursing staff
A
Failure of Refrigerators /Deep Freeze
If generator not managing loadarrange for portable eskies and orportable generators to maintainfridges and freezers
Ensure air conditioning for pharmacyconnected to emergency power
Check availability of emergencygenerator power
Pharmacy DirectorEngineering
Ensure pharmacy is a priority areawhen air conditioning load shedscheduledArrange access to portable airconditioner
Pharmacy DirectorEngineering
Contact Central Pharmacy fordirection
Consider portable air conditioner Pharmacist
Highlight potential inventory fordestruction if temperature extreme
Monitor fridges
Failure of air conditioning- pharmacy
Unable to maintainair temperaturebelow 25'C
Higher load on fridges Director ofPharmacy
A
No drug deliveries fromBrisbane
May not have drugavailable whenrequired
Maintain stock levels to allow for supplychain interruption of three daysObtain stock from Symbion Townsville
Maintain max mins monthly
Ensure on line ordering from Symbionis available
Director ofPharmacyDirector ofPharmacy
B
Page - 168 28/08/2013
PROSERPINE HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?Loss of Power / equipmentfailure
No CT Service.Use alternate investigation if possible.
Outsource to local private practices.Put CT Gantry onto emergencypower.
Medical ImagingStaff and DON &FM / Medical staff B
No Xray service
Key equipment on UPS.Emergency powerMobile x-ray units
Test and maintain UPS. AssessEmergency power for x-raygenerator.
Medical ImagingStaff and DON &FM / Medical staff B
No UltrasoundService.
Equipment on emergency power. Usealternate test
Test and maintain UPS. AssessEmergency Power.
Medical ImagingStaff and DON &FM / Medical staff B
Ensure one steriliser on emergency power Identify emergency power supply tosterilisers
NUMB
Alternative sterilisation methods Investigate alternative sterilisationmethods eg , chemical sterilisationEnsure full stock levels of sterileequipment available prior to criticalperiodsIdentify and prioritise critical services
NUM and Nursingstaff
B
Failure of steriliser Unable to processward and theatreinstruments
Rationalise service to emergency use only NUM/DON&FM
No washer/disinfectorconnected to emergencypower.
Unable to processreusable medicalequipment/instruments.
Manually wash all equipment. Explore the possibility of connectingof one machine to emergency power.
B
Have maximum stores available Prepacked and ensure maximumstore of sterile linen
Rationalise use of linen Consider alternative supplier
Alternative supplier Order extra supplies of disposablelinen
Failure of sterilised linenservice
No Sterile Linenbundles
Use disposable linen
NUM and Nursingstaff
B
Failure of Infantresuscitation trolleys
Suction and oxygennot immediatelyavailable
Use emergency generator power Ensure trolleys are plugged into redemergency power points.
Midwives A
Ensure twin-o-vac available
Ensure alternate supply eg portablegenerator
Ensure oxygen cylinders availableand full
CMC
Unable to maintaininfant warming
Ensure alternate warming devicesavailable
Consider bubble wrap, gladwrap Midwives / CMC
Fill Blanket warmer with blankets andlinen
Page - 169 28/08/2013
PROSERPINE HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?
Dry babies well. Wrap & dress warmly
Place baby in bed with mother
Use emergency generator power Ensure trolleys are plugged into redemergency power points.
Midwives
Revert to manual positioning Adjust bed to optimal height prior tocritical dates
Midwives / CMC
Failure of electric deliverybeds
Positioning for birthmore difficult
Inform staff & patients CMC
B
Use emergency generator power Ensure trolleys are plugged into redemergency power points.
Midwives
Identify at risk patients & instigateintermittent monitoringEnsure adequate supply of batteryoperated Doppler’s and gel.
Use battery-powered ultrasound Doppler. Ensure access to Pinard stethoscope CMC
Failure ofCardiotocograph (CTG)/pH scalp monitoring
Unable to performcontinuous foetalheart monitoring
Educate staff in use
B
Run on emergency generator power .Run on gases if no power Oxygendriven) for 90 minutes only. Monitor ptfor 40 minutes on battery from PACUmonitors
Check access to emergency poweroutlets. Manuallyventilate. Manually physicallyassess
Nurse UnitManagerAnaesthetic staff
Use backup cylinder supplies of oxygen,nitrous oxide & air
Ensure supplies of cylinder gassesavailable
Loss of power tomachine
Hand ventilate Ensure adequate supply of handoperated ventilation equipment -Disposable manual resuscitator
A
Inaccurate deliveryof anaestheticgases
Locate and provide air / oxygendriven ventilator (oxylog)
NUM A
Failure of anaestheticmachines & ventilators
Unable to ventilatepatients
Cancel elective surgery DON & FM / NUM B
Failure of laparoscopiccamera / light lead
Unable to performlaparoscopicsurgery (may be
Revert to non laparoscopic methods Notify surgeons, medical, nursing andbooking office
NUM and clinicalstaff
A
Page - 170 28/08/2013
PROSERPINE HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?
Postpone all non urgent surgery Contact non urgent patients andinform re need to reschedule at laterdate
NUM /Administrationsofficer bookings.
done if generatoron emergencypower).
ensure list of procedures unable to beunder taken available at theatre frontdesk
Bookings/ORManager
A
Failure of diathermymachine
Unable to performelectricalcoagulation (maybe done ifgenerator onemergency power).
Revert to ties/sutures Ensure adequate supply of ties andsutures
NUM andOperating theatreCN
A
Failure of operating table. Unable to positionpatient
Revert to manual processes Adjust bed to optimal height prior tocritical dates Purchasemanual override for table.
Nursing staff
Notify surgeons, medical, nursing andbooking office
NUM & DON / FM
Identify suitable patientsContact non urgent patients andinform re need to reschedule at laterdate
bookings officers
Staff education – availability of typesof cases able to be done
NUM
Failure of Sterilisingequipment for scopes (ONEMERGENCY POWER).
Unable to steriliseendoscopic /laparoscopic andorthoscopicequipment
Consider open procedures where clinicallyindicated
List of procedures unable to be undertaken available at theatre desk
A
Visual readings · Ensure adequate stock ofbatteries
Nursing Staff
· Inform & educate staff CNC
Failure of glucometer Potential fordecreasedaccuracy in bloodglucose readings Formal laboratory blood glucose analysis
for abnormal results· Develop policy for formal
laboratory testMedical Staff A
Ensure access to emergency power · Identify access to emergencypower outlet
NUM
Use on battery power · Keep batteries fully charged onemergency power
NUM
Failure of 12 Lead ECGmachine
Unable to diagnoselife threateningconditions
· Identify location of alternativeECG machines
Nursing Staff
A
Page - 171 28/08/2013
PROSERPINE HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?
· Inform and educate staff CNCFailure of Pulse oximeters Unable to
determine oxygensaturation
Increase nursing observationAccess other portable units from facility/Health Services if available
· Ensure staff to act as a runnerare available
NUM B
Use alternate feeding methods · Develop a procedure forbolus/gravity feeding
CNC / nursing Staff
· Ensure adequate supply oftubes and feeds
NUM
· Manually titrate drip rate ifnecessary
nursing staff B
Failure of Enteral feedpumps
Difficulty inmaintaining patientnutrition
· Inform and educate staff Educator
Failure of non-invasiveBlood Pressure monitors
Unable toelectronicallymeasure bloodpressure readings
Use manual sphygmomanometer · Ensure adequate number ofsphygmomanometers
NUM A
Page - 172 28/08/2013
Business Continuity PlanProserpine Hospital – Utilities Services
PROSERPINE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Loss of mains power tohospital.
Inability to supply mainspower to facilities
Emergency powergeneration
Ensure emergencygenerator is supplying.
Business Manager,Operational ServicesSupervisor. A
Confirm essential equipmentconnected to generatorpower outlets
Staff each area.
A
Ensure essential lights andequipment supplied withuninterrupted power (UPS)battery (e.g.) theatre lights
Business Manager,Operational ServicesSupervisor.
A
Consider need to purchaseextension leads
Business Manager,Operational ServicesSupervisor. A
Continue testing andmaintenance schedule forgenerators AS/NZS 3009-1998
Business Manager,Operational ServicesSupervisor.
A
Ascertain L/per hour fuel useof generator
Business Manager,Operational ServicesSupervisor. A
Ensure fuel reservesavailable for generator forlong term use.
Business Manager,Operational ServicesSupervisor. A
Ensure manual fuel pumpingcapability
Business Manager,Operational ServicesSupervisor. A
Investigate legal/safe levelsof fuel storage on premises
Business Manager,Operational ServicesSupervisor. A
Ration use of emergencypower
Identify generator loadcapacity
Hospital Executive
A
Identify potential for load-shedding and developprocedures
Business Manager,Operational ServicesSupervisor. A
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PROSERPINE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Use alternate powersources
Fully charge batteries on allessential equipment
NUM
A
Supply additional lighting Locate/purchase torches/lanterns and batteries
NUM
A
Use natural lighting -openwindows and doors
All staff
A
Use alternate emergencygenerator
Identify alternate supplierseg SES, Local industries,mines/mills, Army, Hirecompany
Hospital Executive
A
Discharge/ relocate patientswithin facility
Identify patients fordischarge or relocation
Medical Superintendent
A
Inform and educate staff Hospital Executive
A
Consider activation ofDistrict Disaster Plan
Consult current DistrictDisaster Plan for process
District CEO, DON/FacilityManager A
Close Facility Liaise with alternativeservice provider for care ofpatients
District CEO, DON/FacilityManager, MedicalSuperintendent A
Transfer patients out & closefacility
Hospital Executive
A
Staff Education Educate staff oncontingency arrangements
Hospital Executive
ALoss of water supply forgeneral use, e.g., toilets,laundry, boilers, patienthygiene.
Diminished ability tocontinue clinical services
Ration water usage Rationalise services anddevelop plan for waterrestriction
DON/Facility Manager A
Identify alternative watersources
Source / cost alternatesupplies, e.g. On-site tankstorage, Bore water, Watertankers, Fire service supply
DON/Facility Manager A
Initiate use of alternatesupply
DON/Facility Manager A
Use emergency supply Liaise with local council /utilities re emergency watersupply
District CEO, DON/FacilityManager
A
Page - 174 28/08/2013
PROSERPINE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Loss of drinking water Identify alternative suppliesof drinking water
• Buy containers for storageof drinkable water
DON/Facility Manager,Business Manager
A
Source/cost supply ofbottled water
Supervisor OperationalServices
A
Discharge/ relocate patientswithin facility
Identify patients fordischarge or relocation
Medical Superintendent,DON/Facility Manager
A
Contingency Failure Consider activation ofDistrict Disaster Plan
Consult current DistrictDisaster Plan for process
District CEO, DON/FacilityManager
A
Close facility Liaise with alternativeservice provider for care ofpatient
District CEO, DON/FacilityManager, MedicalSuperintendent
A
Transfer patients out andclose facility
District CEO, DON/FacilityManager, MedicalSuperintendent
A
Staff education Educate staff oncontingency
DON/Facility Manager,Medical Superintendent
A
Failure of seweragesystem
Unable to dispose ofwaste products due towater failure
Ensure facility wide plan Develop facility plan forwaste disposal
Hospital Executive D
Utilise “grey/used” water Inform staff to save waterafter patient hygiene
DON/Facility Manager D
Place bucket for used waterin each toilet cubicle forflushing purposes
Cleaning Services D
Designate toilets to be used Close off toilets not for useand post signs
Business Manager, SupervisorOperational Services
D
Alternate toilet facilities Identify alternate toiletdevices e.g., porta loos, andnumber required and cost ofthese alternatives
Business Manager, SupervisorOperational Services
D
Single patient use bedpans/urinals
Purchase sufficient forimmobile patients
Business Manager, SupervisorOperational Services
D
Rinse with “grey/waste”water and chemical solution
Nursing staff D
Page - 175 28/08/2013
PROSERPINE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Inform staff of InfectionControl policy
NUM, Infection Control CNC D
Discharge/ relocate patientswithin facility
Identify patients fordischarge or relocation
Medical Superintendent D
Consider activation ofDistrict Disaster Plan
Consult current DistrictDisaster Plan for process
District CEO, DON/FacilityManager
D
Liaise with local council /utilities re emergency watersupply
DON/Facility Manager D
Back up of effluent dueto council pump failure
Isolate hospital drainagesystem from main system
Liaise with council to closevalves
DON/Facility Manager ,Business Manager
D
Arrange for septic tankpumping truck to pumpsewerage out of hospitalpipes
DON/Facility Manager ,Business Manager
D
Failure of contingency Close facility Liaise with alternativeservice provider for care ofpatient
Medical Superintendent D
Transfer patients out, closefacility
District CEO, DON/FacilityManager
D
Staff education Educate staff oncontingency plans
Hospital Executive D
Loss of LPG supply Unable to supply torelevant areas.
Establish security of the siteand risk assess immediateneeds.
Secure LPG site andimplement retrieval/disposalof hazardous material
Business Manager,Operational ServicesSupervisor.
B
Arrange urgent supply ofportable LPG cylinders
Identify number of cylindersrequired and allocate as perpriority listing.
Operational ServicesSupervisor.
B
Arrange for supplier to fillstorage tanks
Operational ServicesSupervisor.
B
Reduce use of LPG topriority areas
Identify priority areas for gasrationing
Operational ServicesSupervisor.
B
Unable to providecooking facilities
Use alternate energysource or BBQ
Identify alternate energysources for cooking.
Operational ServicesSupervisor.
B
Page - 176 28/08/2013
PROSERPINE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Identify alternate facility toprepare patients meals. egMOW Proserpine/ProserpineNursing Home
Operational ServicesSupervisor.
B
Unable to provide hotwater
Heat water with alternateenergy source eg GasQuick heat water heater.
Identify alternate energysources for water heating
Operational ServicesSupervisor.
B
Wash / clean with coldwater
Identify cleaning processesthat can use cold water oruse disposable ware.
Operational ServicesSupervisor.
B
Develop procedure forlaundry processes
Operational ServicesSupervisor.
B
Develop procedure for wardcleaning
Operational Servicessupervisor, Infection ControlCNC
B
Staff Education Educate staff oncontingency plans
CNC B
Internal Telephone failureUnable to communicateinternally.
Establish extend of problemand likely time for re-establishment ofcommunication.
Urgently contactIT/communications DeptMBH.
Business Manager, SupervisorOperational Services
A/B
Utilise 2 way Radio Locate and centraliseexisting 2 way radios tocommunication centre
Business Manager, SupervisorOperational Services
A/B
Identify critical personneland reallocate 2 way radios(eg) Facility Manager, NUM,ED
DON/Facility Manager
A/B
Utilise mobile phones Locate and distribute mobilephones to key personnel.
DON/Facility Manager
A/B
Maintain and distributedirectory of re-allocatedphone unit numbers
Business Manager
A/B
Develop procedure foremergency phone use andeducate staff
DON/Facility Manager
A/B
Page - 177 28/08/2013
PROSERPINE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Runners Provide staffing and developa planned circuit
DON/Facility Manager,Business Manager A/B
Utilise alternate existingcommunication devices
Consider use of intercoms,nurse call system, WIPphones, PA system, E mail,message board
DON/Facility Manager
A/B
Inform and educate staff DON/Facility Manager
A/BExternal telephone failure(dial in )
Unable to communicateexternally.
Identify alternate means ofcommunication
Liaise with CEO & MediaRelations Officer re localmedia to inform community
DON/Facility Manager
A/BExternal telephone failure(dial out)
Unable to receivecommunication fromexternally.
Utilise mobile phones Distribute mobile phones tokey personnel
DON/Facility Manager,Business Manager
A/B
Limit outgoing calls DON/Facility Manager,Business Manager A/B
Inform and educate staff DON/Facility Manager,Business Manager A/B
Utilise existing radionetworks
Consider use of existingQAS radio phones
Hospital Executive, QAS
A/B
Consider access toemergency services radiosand negotiate for frequency.
DON/Facility Manager,Business Manager
A/B
Identify alternateemergency communicationnetworks
SES, Fire Services, Police,Shire Council vehicles
DON/Facility Manager,Business Manager
A/BEquipment function That ongoing issues
following restoration ofservice.
Check all equipment forfunctionality as soon aspossible after disruption ofpower
Identify all equipment to bechecked in liaison withIT/communications DeptMBH.
DON/Facility Manager,Business Manager
A/B
Inform and educate staff DON/Facility Manager,Business Manager A/B
Loss of ability to securesite
Hospital businessdisruption. Risks relatedto lack of security.
Provide onsite security Engage services of securityfirm as necessary over 24hour period.
DON/Facility Manager,Business Manager.
C
Page - 178 28/08/2013
PROSERPINE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Identify priority areas forsecurity
Hospital Executive C
Provide security presencein critical areas
Hospital Executive C
Closed circuit TV Manual operation of sitesecurity
Increase indoor and outdoorsecurity rounds
NUM, Business Manager C
Assess ability to operatesystem manually
NUM, Business Manager C
Self-opening doors frontentrance. Security locksall entrances.
Manual override of self-opening front entrance doorand unlock all otherentrance doors.
Ensure that doors kept inopen position.
DON/Facility Manager,Business Manager.
C
Keypad locks / swipecard access
Manual override of keypadlocks
Use other means ofsecuring area, e.g., personalalarms for isolated staffmembers, lockablecupboards for medications/expensive equipment
DON/Facility Manager,Business Manager.
C
Exterior lights Provide alternative exteriorlighting
Purchase battery-operatedlights and extra batteries
Supervisor OperationalServices
C
Parking Manual control of parking ifany of the car parks areflooded.
Place "No Parking" signs inthe appropriate areas.
Supervisor OperationalServices
C
Helicopter landing site Provide alternative lightingfor helicopter landing site
Purchase battery-operatedlights for landing site
Supervisor OperationalServices D
Staff education Educate staff oncontingency plan
DON/Facility Manager,Business Manager. D
Loss of ability to protectstaff and patients
Increased risk to staff Roster extra staff forescorts
Ensure availability of extrastaff
NUM & Hospital Executive
C
Review emergency call inroster
NUM & Hospital Executive
CLoss of ability to protectstaff and patients
Duress alarms Provide alternative alertsystem for nurses
Purchase hand held audiblealarms
DON/Facility Manager,Business Manager. C
Consider purchase ofwhistles
DON/Facility Manager,Business Manager. C
Page - 179 28/08/2013
PROSERPINE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Fire alarms Aim to have fire alarmscompliant.
Check fire alarms DON/Facility Manager,Business Manager. C
Provide alternative powersource for alarms
Ensure alarms areconnected to generatorpower
DON/Facility Manager,Business Manager.
C
Messenger sent to all unitsin event of fire.
Appoint messenger DON/Facility Manager,Business Manager. C
Ensure fire evacuationprocedures in facilitydisaster manual.
Review fire procedures andpolicy
DON/Facility Manager,Business Manager.
C
Sensor alarms formedical gases
Revert to manual process Visual check of gauges Operational Wards persons
C
Equipment function Check all equipment forfunctionality as soon aspossible after disruption ofpower
Identify all equipment to bechecked
Hospital Executive, All staff
C
Inform and educate staff Hospital Executive
C
No safety/evacuationlighting available
Provide additional portablelighting
Identify and sourcealternative lighting
Supervisor OperationalServices C
Staff member to placelighting in strategic areas forsafety
Supervisor OperationalServices
C
Issue clinical staff withtorches
Supervisor OperationalServices C
Failure of hot watersystems
Loss of steam forsterilisation, laundry, andhot water
Arrange for laundrysterilisation and provision ofhot water from externalsources.
Access available services DON/Facility Manager,Supervisor OperationalServices
B
Equipment Function Check all equipment forfunctionality as soon aspossible after disruption ofpower
Identify all equipment to bechecked
Supervisor OperationalServices
B
Inform and educate staff Supervisor OperationalServices
Page - 180 28/08/2013
PROSERPINE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Loss of vehicles or fuelsupply.
Unable to providetransport services
Identify and rationalise useof available vehicles
Develop a plan forcentralising vehicles withWhitsunday CommunityHealth
Business ManagersProserpine Hosp and WCHC
C
Prioritise use Hospital Executive C
Discontinue non-essentialservices
Notify clients of potential fordisruption to normal services
Department staff C
Re–admit at risk patients ifnecessary
Medical staff Communityhealth staff
C
Failure of EFTPOS fuelcard service
Arrange credit facility Liaise with local fueldistributor for credit facilitiesfor fleet vehicles
Business ManagersProserpine Hosp and WCHC
C
Unable to transportsupplies from/to facility
Use alternate methods fortransport of supplies
Identify and engageexternal contractors
Business ManagersProserpine Hosp and WCHC
C
Failure of File Server Loss of access todesktop applications
Inform IT and take directionfrom IT Dept, MBH.
Urgently contact IT DeptMBH.
DON/Facility Manager,Business Manager
D
Switch to backup fileserver.
• Flag PC to substitute asreplacement file server
• Information ServicesManager
D
Worst case – switch tomanual system.
• Conduct full backup of fileserver
• Information ServicesManager
D
• Reconfigure new file server • Information Services staff D
• Load backup data • Information Services staff D
• Revert back to originalserver
• Information Services staff D
• Copy amended data • Information Services staff D
Failure of Local AreaNetwork
Loss of access todesktop applications
Inform IT and take directionfrom IT Dept, MBH.
Urgently contact IT DeptMBH.
DON/Facility Manager,Business Manager
D
Switch to condensed LocalArea Network system.
Flag PC to substitute asreplacement
• Information ServicesManager
D
Page - 181 28/08/2013
PROSERPINE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Switch to stand aloneprocessing
• Conduct full backup if fileserver
• Information ServicesManager
D
• Switch to manualProcessing.
• Reconfigure new file server • Information Services staff D
• Load backup data • Information Services staff D
• Revert back to originalserver
• Information Services staff D
• Copy amended data • Information Services staff D
Air conditioning failure Electrical or manual fan Identify patients requiringcooling, Use windows. Notifyand inform patients andstaff.
Lighting failure Difficulties in patientobservation and care.
Utilise emergency lighting Identify provision foremergency lighting
business manager /Operational Services Manager
B
Relocate immobile patientsto best lit areas
B
Maximise natural lighting Clean and maintain windowsand fittings
Nursing staff C
Ensure blinds/curtains open C
Ensure adequate supplytorches / battery operatedlights and batteries
C
Increased risk for patientsand staff
Clear patient areas, workareas and corridors of allhazards
C
Utilise alternate lighting Identify and sourcealternative lighting
Nurse Unit Manager C
No safety/evacuationlighting available
Maintain WH&Sprecautions
Staff member to placelighting in strategic areas forsafety
Nurse Unit Manager /All staff B
Page - 182 28/08/2013
PROSERPINE HOSPITAL - UTILITIES
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Issue clinical staff withtorches
Nurse Unit Manager /All staff B
Provide additional portablelighting
C
Page - 183 28/08/2013
Business Continuity Plan
Sarina Hospital – Clinical & General
SARINA HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?HBCIS AccessFailure
Unable to registerpatients
No patient ID labels
Manual registration
Manual Process
Adequate supply downtime forms
Hand write requestsEnsure blank details are recorded inchart
Administration Staff
Administration StaffAdministration Staff
B
Emergency DepartmentModule failure
Unable to utiliseTRIAGE treatmentandadmission/dischargeUnable to recordstatisticalrequirements
Manual recording.No written record of UR Numbersmaintained on siteRetrospective data entry
Ensure details are recorded in thechart
Check and update missing data
Administration Staff
Administration StaffNursing staff
C
Printing services Failure Unable to printresults/labels
Manual recording – lead to adequate staffnumbers
Ensure adequate staffing to coverworkload
Business ManagerAdministration Staff B
BComputer failure Unable to generate
ID labels
Unable to trackpatient location andbed statusUnable to providepatient dietaryrequirements
Record patient details manually
Revert to manual process
Revert to manual process
Ensure supply of HBCIS downtimeformsPre-print labels on existing patientsHand write on blank labels for newadmissionsUpdate patient location and bedstatus at regular intervalsUpdate patient diet lists and haveavailable for collection by cateringservices
Administration StaffNursing staff
C
Page - 184 28/08/2013
SARINA HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?Telephone Failure No internal or
externalcommunications
Refer to facility wide telecommunicationsplan
Inform and Educate staff Nurse UnitManagerShift Team Leader
C
FAX Failure Unable to receiveoe send patientinformation
Utilise alternate lines of communication Send patient information by courier
Delay transfer of information untilservices resumed
Nurse UnitManager
Medical &AdministrationStaff
B
BPhotocopy Failure Unable to copy
documentsUtilise alternate lines of communication Telephone Communication
Send original documents with thepatient in chartDelay transfer of information untilservices resumed
All Staff
A
Oxygen Supply Disrupted Use oxygen cylinders Ensure adequate supply of cylinders
Ensure all staff educated in cylinderchangeoverConsider co-locating high oxygenusers
OperationalOfficers
All Staff
D
Failure ofRefrigeration/Cool Rooms
Food spoilage referto Food Safety Plan
Essential Fridges on emergency powerSource Food off campus
Consider long shelf life food products
Assess availability of emergencypower
Develop a plan for preparation &transport of food from otherappropriate sourcesPurchase dry/tinned foodConsider purchase of long life milkConsider purchase of bottled waterfor drinking
CookBusiness Manager
B
Refrigeration Vaccine Drugs and medicalsupplies requiringrefrigeration maybecome unstable
Place drugs in refrigerators which areconnected to emergency power supply
Use eskies and ice
Review emergency power outlets andmanage vaccines as per infectioncontrol guidelines
Monitor refrigerator temperature withthermometerUtilise SBVP EskyInform & Educate staff
Nurse UnitManagerEngineering Staff
A
Page - 185 28/08/2013
SARINA HOSPITAL – CLINICAL & GENERALA = Up to 24hrs B = Up to 5 DaysC = Indefinitely D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
HOW LONG CANYOU FUNCTIONWITHOUT THIS
SERVICE?Failure of Dishwasher Refer to Food
Safety PlanUse Disposables Ensure adequate supply of
disposablesCookBusiness Manager C
BLoss of communicationwith pre Hospital transferservices and referralcentres
Unable tocommunicate withQAS
Unable tocommunicate withGP’s
Use alternate communication channels
Develop an alternate referral dischargeprocess
Consider the use of Mobile Phone ifnetwork is operationalUse 2 way radio from Community e.g.CouncilDevelop criteria for referral based onavailable servicesDevelop pro forma for requiredpatient information
Nursing staff
C
Page - 186 28/08/2013
Business Continuity PlanSarina Hospital – Utilities Services
SARINA HOSPITAL - UTILITIESA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Loss of LPGsupply
Unable to provide cookingfacilitiesUnable to provide hotwate
Secure LPG site and implementretrieval/disposal of hazardousmaterialArrange urgent supply ofportable LPG cylinders
Use alternate energy sourceGas Cook top or BBQHeat water with alternate energysource Gas Quick heat waterheater.Wash / clean with cold water
Dishwasher heats own waterStaff Education
Engineer to establish security of the site andrisk assess immediate needs.Identify number of cylinders required andallocate as per priority listing.Arrange for supplier to fill storage tanks ifnot damagedIdentify alternate energy sources for cookingIdentify alternate energy sources for waterheatingIdentify cleaning processes that can usecold water or use disposable wareIdentify alternate washing regime for patienthygiene.No remedial action requiredEducate staff on contingency plans
Manager Engineering
Business manager
CNC/Managers
A
B
Oxygensupplydisrupted
Use cylinder oxygen Ensure adequate supplies Operational Officers/Business Manager A
Inability tosupply mainspower tofacilities
Emergency power generation Identify existing supply of emergency powergeneration
Refer to power points/ outlets withemergency generation in each areaConfirm essential equipment only connectedto generator power outletsEnsure essential lights and equipmentsupplied.Consider need to purchase extension leadsDevelop a procedure for use of emergencypower in each area and inform staff
Manager EngineeringNurse Unit Manager
Nurse Unit Manager
A
A
Page - 187 28/08/2013
SARINA HOSPITAL - UTILITIESA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Ration use of emergency powerUse alternate power sources
Supply additional lighting
Discharge/ relocate patientswithin facility
Consider activation of MHHSDisaster PlanClose Facility
Staff Education
Contact Engineering/Contractor to ensureadequate fuel source for use of generatorEnsure fuel storage standards aremaintainedIdentify generator load capacity
Fully charge batteries on all essentialequipmentLocate/purchase torches/ lanterns andbatteriesUse natural lighting -open windows anddoorsIdentify patients for discharge or relocationInform and educate staffConsult current MHHS Disaster Plan forprocessLiaise with alternative service provider forcare of patients
Transfer patients out & close facilityEducate staff on contingency arrangements
Manager Engineering
Nursing staff
All ManagersMHHS Manager
MHHS Manager /MedicalSuperintendent only
Nurse Unit Manager
A
A
ALoss of watersupply forgeneral use,e.g., toilets,patienthygiene
Ration water usage
Identify alternative water sources
Identify alternative supplies ofdrinking water
Rationalise services and develop plan forwater restriction
Source / cost alternate supplies, e.g. / Watertankers / Fire service supplyInitiate use of alternate supply
Consider purchase of bottled waterLiaise with Renal Dialysis Unit to saveempty dialysate containers for water storageBuy containers for storage of drinkablewater
MMHS Executive •Manager Engineering
Manager Engineering
MHHS Executive /Manager Engineering
MHHS Executive A
Page - 188 28/08/2013
SARINA HOSPITAL - UTILITIESA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Loss of drinking wate
Contingency Failure
Discharge/ relocate patientswithin facilityConsider activation of MHHSDisaster PlanUse emergency supply
Close facility
Staff education
Identify patients for discharge or relocationConsult current MHHS Disaster Plan forprocessLiaise with local council / utilities reemergency water supplyLiaise with alternative service provider forcare of patientTransfer patients out and close facilityEducate staff on contingency
MHHS Manager
Nurse Unit ManagersSewerage Unable to dispose of
waste products due towater failure
Ensure facility wide plan Develop facility plan for waste disposal MHHS ExecutiveD
Ensure Localcouncil andPublic HealthUnitinvolvement.
Utilise “grey/used” water
Designate toilets to be used
Alternate toilet facilities
Single patient use bedpans/urinals
Discharge/ relocate patientswithin facilityConsider activation of MHHSDisaster Plan
Inform staff to save water after patienthygienePlace bucket for used water in each toiletcubicle for flushing purposesClose off toilets not for use and post signsIdentify alternate toilet devices e.g., portaloos, and number requiredSource supply / cost of alternate devicesPurchase sufficient for immobile patientsRinse with “grey/waste” water and chemicalsolutionInform staff of Infection Control policyIdentify patients for discharge or relocationConsult current MHHS Disaster Plan forprocessLiaise with local council / utilities reemergency water supplyArrange for septic tank pumping truck topump sewerage out of hospital pipesLiaise with alternative service provider forcare of patientTransfer patients out, close facilityEducate staff on contingency plans
Nurse Unit Manager
Operational Services
Nurse Unit Manager
All staff
MHHS Manager
Manager Engineering
D
Page - 189 28/08/2013
SARINA HOSPITAL - UTILITIESA = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction withoutthis service?
Failure of contingency Close facility
Staff education
Medical SuperintendentNurse Unit ManagerManagers
DPower failure Mains power not
available. Generatorsupplies emergencypower
Refer to mains power failure plan Inform and educate staff DON/NUM/BM/Engineering B
Lightingfailure
Difficulties in patientobservation and care
Increased risk for patientsand staffNo safety/evacuationlighting available
Utilise emergency lighting
Maximise natural lighting
Utilise alternate lighting
Maintain WH&S precautions
Provide additional portablelighting
Identify provision for emergency lightingRelocate immobile patients to best lit areasClean and maintain windows and fittingsEnsure blinds/curtains openEnsure adequate supply torches / batteryoperated lights and batteriesClear patient areas, work areas andcorridors of all hazardsIdentify and source alternative lightingStaff member to place lighting in strategicareas for safetyIssue clinical staff with torches
Engineering staff
Nursing staff
Operational Staff
All staff
Nurse Unit Manager Allstaff
B
Page - 190 28/08/2013
Business Continuity PlanEnvironmental Services
Environmental Services
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Lift Failure Unable to transportpatients to differentlevels within facility
Ensure one lift operates onemergency power
Utilise alternate methods oftransporting patients
Consider utilising groundfloor facilities
Minimise patient transfers
Review existing supply ofemergency power
Walk patients
Consider scoop stretchers,fire blankets, stair walkers,cardboard stretchersDevelop facility plan forlocating new admissions
Critical transfers only
Ensure all staff aware offacility Fire / Evacuation plan
Engineering staffDisaster Committee
Wards person
MHHS Executive
MHHS Executive
Medical staff
Unit Manager
D
Wall oxygen supplyfailure.
Wall oxygen notavailable
Use cylinder oxygen Order required cylindersfrom central storage area.
Ensure all oxygen cylindersfull
Ensure correspondingnumber of oxygen fittingsavailable at ward level.
Ensure all staff educated incylinder changeover.
Consider co-locating highoxygen users
Wards person
Wards person
Wards person
Wards personUnit ManagerEducatorNursing staffmedical Staff
C
Page - 191 28/08/2013
Environmental Services
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Telephone failure No internal / externaltelephonecommunications .
Refer to facility widetelecommunications plan
Inform and educate staff Unit Manager
Power failure Mains power notavailable
Refer to mains powerfailure plan
Inform and educate staff Unit Manager /Nurse Educator D
Lighting failure Difficulties in patientobservation and care.
Increased risk forpatients and staff
Utilise emergency lighting .Torches in all areas.
Maximise natural lighting
Utilise alternate lighting
Maintain WH&Sprecautions
Refer to Facility wide powerfailure plan
Identify provision foremergency lighting
Relocate immobile patientsto best lit areas
Clean and maintain windowsand fittings
Ensure blinds/curtains open
Ensure adequate supplytorches / battery operatedlights and batteries
Clear patient areas, workareas and corridors of allhazards
Educate staff
Engineering staffNUMNursing staffSecurity
Cleaning staffWards person
All staff
Unit Manager
Unit Manager /All staff
Educator
C
C
Outside furniture/objects Flying objects Refer to cyclonepreparation policy
Ensure all flying objects aresecure
Wards persons
Linen Supplies Unable to maintainadequate linenmanagement if Laundryeffected - potentialinfection control risk
Beds only to be changed ondischarge and infectiouspatients
Ensure spare linen prepared Disaster CommitteeCorporate Services
A
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Environmental Services
A = Up to 24hrsB = Up to 5 DaysC = IndefinitelyD = Cannot Operate
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Inadequate WasteCollection & Disposal
Build up of clinical andgeneral waste productsin unitInfection Control Issue
Use additional disposalmethods
Ensure where possible JJRichards has emptiedcompactus. Supplyadditional bins
Disaster CommitteeCorporate Services
C
Staffing Increased manual tasksmay influence workload
Roster extra staff on duty
Place staff "on call"
Estimate staffing numbersrequired for 24 hour periodPrepare rostersLiaise with agencies forextra staffCall in staff
All managers
Duty managers
D
Failure of EmergencyAlarms
Unable to provide safeand secure environment
Increased staff vigilance
Refer to security plan
Schedule regular patientrounds
Direct notification viaphone switch or runner toCommunication Centre tocontact fire services,security & police
Inform and Educate Staff
Disaster CommitteeCorporate ServicesSecurity
All staffB
Failure of Lamson System Unable to transportspecimens
Revert to manual process Inform and educate staff Unit ManagerEducator
Engineering staffDisaster Committee
Wards person
D
In addition:
Environmental Services Manager/Supervisors and Team Leaders to have contact details of all staff All management team to the hospital if safe to travel Environmental Services Manager attendance to Emergency Disaster Committee Meetings Create a ‘Disaster team’ within Environmental Services (or Corporate Services) If we have notice of the disaster:
o Ensure adequate supplies of chemicals for at least a week
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o Attendance at emergency meetingso Liaise with JJ Richards in regards to waste – empty compactus, additional large bins, additional pick up of sharps and clinical
wasteo Staff meetings – rostering, ensure contact details are correct, draft in from other areas ie gardenerso Wet weather protection – heli-pad, Kids/WHU/Labour wardo Enough torches/batterieso Continually update staffo All outdoor furnishings/objects removed/tied down/locked securelyo Liaise with NUMs/Bed Managers for early discharges – impact on wardies/cleanerso Enough buckets/bins for water
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BUSINESS CONTINUITY PLANCatering Services
Limited connections to the generator during power failure.Problem Impact Contingency Task Responsibility
How long can you functionwithout this service?
Failure ofcomputerised systems
Unable to accesselectronic forms androsters
Revert to manualsystems
• Ensure adequatesupply of forms.
• Catering ManagerCatering Supervisor
BFailure ofcomputerised systems
Unable to accessinpatient status anddietary requirements
Revert to manualsystems
• Allocate staff tomanually collectstats/menus from wards
• Catering ManagerCatering Supervisor
AFailure of energysupply to ovens
No hot/cooked food Use the 1 oven withemergency capability
•Assess and ensureemergency power isworking.
• Catering ManagerCatering Supervisor
AFailure of energysupply to cookingequipment
No hot/cooked food Cold menu • Ensure adequatesupplies of cold food
• Catering ManagerCatering Supervisor
AFailure ofRefrigeration / coolrooms
Food spoilage Essential fridges onemergency power
• Coolrooms areconnected toemergency power
• Catering Manager• Engineering staffCatering Supervisor
CFailure ofRefrigeration / coolrooms
Food spoilage Restrict menu • Utilise cyclone menu • Catering ManagerCatering Supervisor
BFailure ofRefrigeration / coolrooms
Food spoilage Restrict menu • Purchase dry / tinnedfood
• Catering ManagerCatering Supervisor
BFailure ofRefrigeration / coolrooms
Food spoilage Modify choices • Consider purchase oflong life milk
• Catering ManagerCatering Supervisor
B
Water quality Patient & staff health Bottled water • Consider purchase ofbottled water fordrinking
• Catering Manager •Catering Supervisor
CFailure ofDishwashers
Unable to ware wash Use disposables • Adequate supplydisposables
• Catering ManagerCatering Supervisor B
Inability to transportmeals
Unable to deliver patientmeals to floors abovekitchen area
Utilise emergencypower
• Ensure at least one liftoperational onemergency power
• Engineering staff A
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Inability to transportmeals
Unable to deliver patientmeals to floors abovekitchen area
Airline lunches(prepacked lunches)
• Develop simple menufor easy transport
• Catering ManagerCatering Supervisor
AInability to transportmeals
Unable to deliver patientmeals to floors abovekitchen area
• Consider use ofvolunteers to transportmeals
Coordinate volunteers • Catering ManagerCatering Supervisor
AInability to cater forfunctions
No catered functionsheld
Resume catering whenservice is available
• Inform staff • Catering ManagerCatering Supervisor C
Inability to maintainstaff hygiene
Risk of food bornedisease
• Refer to facility WideInfection Control Plan
• Inform and educatestaff
• Catering ManagerCatering Supervisor
BPotential for foodspoilage
Potential for diseaseoutbreak
• Monitor refrigerationand temperature
• Increased staffvigilance
• Catering ManagerCatering Supervisor C
Potential for foodspoilage
Potential for diseaseoutbreak
• Monitor refrigerationand temperature
• Ensure supply of auditforms/ thermometers
• Catering ManagerCatering Supervisor B
Equipment Function Unable to guaranteeequipment accuracy
Check all equipment forfunctionality as soon aspossible after disruptionof power/failure ofmachines
Identify all equipmentto be checked
• Catering Manager
A• Inform and educatestaff
• Catering Manager
C
Mode of Operation A: Hours up to 24hrs
B: Days up to 5C: Weeks –
Indefinitely
D: Cannot Operate
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BUSINESS CONTINUITY PLANLinen ServicesLaundry cannot function if there is no electricity as the generator is not connected.
Boiler function is critical to the laundry. If boiler not operating:- No laundry Service.
Problem Impact Contingency Task Responsibility How long can youfunction without thisservice?
Emergency Power Reduced production Utilise emergency power Identify access toemergency power
Manager Linen ServicesSupervisor LinenServices
C
Emergency Power Reduced production Utilise available existinglinen
Identify minimum usagerequired
Manager Linen ServicesSupervisor LinenServices
B
Emergency Power Reduced production Evaluate linen resources Rationalise the use oflinen
Manager Linen ServicesSupervisor LinenServices
B
Emergency Power Reduced production Evaluate linen resources Develop procedures tominimise patient useincluding ‘top & tail’,change only whensoiled, patients to supplyown linen where able
Manager Linen ServicesCNC Infection ControlNUM
B
Equipment breakdown /emergency power problem
No production Utilise alternative linenservice.
Review existingarrangements withexternal provider andnegotiate forsupply/removal linen
•Manager Linen ServicesSupervisor LinenServices
D
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Lifts out of service Develop plan fortransport of soiled andclean linen andrelocation of staff
• Manager LinenServicesSupervisor LinenServices
A
Boiler not working Unable to process anylinen at all.
Outsource all linen toprivate provider.
Arrange for linentransport to privateservice.
• Manager LinenServicesSupervisor LinenServices
D
No water Unable to process anylinen at all.
Outsource all linen toprivate provider.
Arrange for linentransport to privateservice.
• Manager LinenServicesSupervisor LinenServices
D
Supplies of chemicals Reduced production Ensure chemical stocksare adequate
Order extra supplies incyclone season
• Manager LinenServicesSupervisor LinenServices
C
Mode of Operation A: Hours up to 24hrs
B: Days up to 5C: Weeks –
IndefinitelyD: Cannot Operate
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Emergency Call Directory
Contact List – Internal
Person Responsibilities Contact Number Email
Kerry McGovern(MHHS ChiefExecutive Officer)
QH & Board Liaison 4885 6752 Kerry.mcgovern@health.qld.gov.au
David Farlow(EmergencyDirector of MedicalServices)
Health IncidentController
48856755 David.farlow@health.qld.gov.au
Julie Rampton(District Directorof Nursing)
Operations Officer48856763 Julie.rampton@health.qld.gov.au
Rhonda Morton(Chief OperationsOfficer)
Logistics Officer48856753 Rhonda.morton@health.qld.gov.au
Vicki Barrow(Pandemic ProjectOfficer)
Planning Officer48855640 Vicki.barrow@health.qld.gov.au
Danielle Jesser(Public AffairsManager)
Media andCommunicationsOfficer
48855984 Danielle.jesser@health.qld.gov.au
Contact List – External
Key contacts Name Contact number/s
Police 000Emergency Services 000Ambulance 000MedicalSecurityInsurance companySuppliersWater and SewerageGasElectricityTelephone
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Operational ChecklistImmediate Response Checklist
INCIDENT RESPONSE ACTIONS TAKEN
Have you:
assessed the severity of the incident?
evacuated the site if necessary?
accounted for everyone?
identified any injuries to persons?
contacted Emergency Services?
implemented your Incident Response Plan?
started an Event Log?
activated staff members and resources?
appointed a spokesperson?
gained more information as a priority?
briefed team members on incident?
allocated specific roles and responsibilities?
identified any damage?
identified critical business activities that havebeen disrupted?
kept staff informed?
contacted key stakeholders?
understood and complied with anyregulatory/compliance requirements?
initiated media/public relations response?
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Glossary
Business Continuity
Management
The framework of controls implemented and steps undertaken by
an organisation to manage its business continuity risks. The
primary objective of these controls is to ensure the uninterrupted
availability of its key business resources that support key (or
critical) business processes.
Business Continuity
Planning
A process that helps develop a plan document to manage the risks
to the Mackay Hospital and Health Service, ensuring that it can
operate to the extent required in the event of a crisis/disaster.
Business Continuity
Plan
A document containing all of the information required to ensure
that the Mackay Hospital and Health Service is able to resume
critical activities should a crisis/disaster occur.
Critical Infrastructure A service, facility or a group of services or facilities, the loss of
which will have severe effects on the physical, social, economic or
environmental wellbeing or safety of the community
Essential Service An indispensable supply or activity
Emergency Control
Organisation
A structured organisation that will initiate an appropriate response
to emergency situations. During emergencies instructions given by
the EOC personnel shall overrule the normal management
structure.
Incident Business interruption, adverse event, disaster – a series of events
beyond the capacity and resources of a unit or facility to manage
eg fire, flood, loss
Key activities Those activities essential to deliver outputs and achievement of
overall facility objectives.
Recovery Time
Objective (RTO)
the time from which you declare a crisis/disaster to the time that
the critical facility functions must be fully operational in order to
avoid serious financial loss.
Resources the means that support delivery of an identifiable output and/or
result. Resources may be money, physical assets, or most
importantly, people.
Risk Management is the process of defining and analysing risks, and then deciding on
the appropriate course of action in order to minimise these risks,
whilst still achieving facility goals.
Amendment register and version control
Version Date Prepared by Comments1 26/8/13 Raelene Burke Updated from 2009 version23
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APPENDIX 1
Terms of Reference - Emergency Preparedness andContinuity Management Sub-Committee
The Mackay Hospital and Health Service Emergency Preparedness and Continuity Management Sub-Committee will ensure the Mackay Hospital and Health Service is able to respond effectively to externaland internal potential and actual emergencies and disasters.
Aim:
The Committee will oversee the implementation of systems, policies and procedures that identify andmanage potential emergency situations that may arise, either internally or externally in terms ofconsequence, exposure, probability and preventative actions.The Committee will assess staff preparedness to deal with emergency situations and, where necessary,develop strategies to improve the preparedness.
Objectives:
The MHHS Emergency Preparedness & Continuity Management Sub-Committee will:
Ensure compliance with relevant standards and legislation. Standards Australia – AS 4083-1997: Planning for Emergencies – Health Care Facilities Standards Australia – HB221:2004 Business Continuity Management Develop and implement appropriate emergency response systems in consultation with relevant
external emergency response organisations. Develop strategies, plans, manuals, processes and procedures to manage internal and
external emergencies. Ensure appropriate training of staff in cooperation with the Liaise with external agencies to ensure responses to both external and internal emergencies
are optimised. Report any risks assessed as Very High or Extreme to the MHHS Executive Identify key internal and external stakeholders and develop strategies for ongoing
communication with these stakeholders.
Membership:
Chief Operations OfficerDistrict Director of Nursing (or delegate)Executive Director Emergency MedicineEnvironmental ServicesHealth Information ServicesManager Building Engineering and Maintenance ServicesOccupational Health & Safety OfficerBed ManagerFire Safety OfficerInformation DivisionClinician
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APPENDIX 2
MODEL HEALTH INCIDENT MANAGEMENT CHECKLISTS(Adapted from the Australian Inter-service Incident Management System)
State Health Coordinator
The State Health Coordinator’s role is to provide the leadership and support for an overall coordinatedhealth response to the health event and the liaison with other agencies to ensure a planned, effectiveand integrated health service response and recovery.
Responsibilities include: Obtain (or provide) briefing from/to the Health Incident Controller; Provide the high level support required by the Health Incident Controller in meeting the
objectives of the health event management plan; Set up the Health Event Management Team and where appropriate with the other agencies
involved in the health response; Activate the Health Emergency Coordination Centre - dependent on the nature of the health
event, this may be in conjunction with another agency(s); Establish a support management structure that is appropriate to the size, nature and
complexity of the health event; Brief and liaise with the SCC or SDCC through the QH Director General or Chief Health Officer; Access external resources and agencies to ensure that the human, physical, fiscal and
communication resources are identified and made available to the Health Event ManagementTeam; and
Maintain a log of all activities.
Health Incident Controller
The Health Incident Controller is responsible for incident management activities including thedevelopment and implementation of strategic decisions and approving the ordering andreleasing of resources.
Responsibilities include: Assume control and obtain incident briefing; Assess incident information; Conduct initial briefing; If required or appropriate activate the Incident Management Team; Ensure planning meetings are conducted; Brief and allocate operational personnel including the Site Medical Commander
(when not already determined) in accordance with the health event managementplan;
Approve and authorise implementation of the management plan Supervise the health response and operations within the health event Coordinate staff activities; Assemble and disassemble response teams and task forces assigned Approve requests for additional resources and requests for release of resources; In consultation with the Media Officer, approve release of information to the news
media; Regularly report to the ‘lead’ agency and upwards; Approve plan for stand-down activities; Ensure safety and welfare of all health personnel; and Maintain a log of activities.
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Site Medical Commander
The Site Medical Commander is responsible for the management and coordination of all public health ormedical resources at the scene of the health event. The Site Medical Commander coordinates theorganisational elements providing medical or public health care at the scene in accordance with the sitemanagement plan and directs its execution. The Site Medical Commander coordinates his/her activitieswith the Site Commanders from Ambulance, Police and Fire services. The relationship between the SiteMedical and Ambulance Commanders is particularly close.
The Site Medical Commander also liaises frequently with the Health Incident Controller (in a largeincident once the EOC has been established) or individual hospital emergency departments (in a smallincident where the EOC support is in effect provided by the facilitating hospital). This communication willensure an accurate flow of information from the scene and appropriate destinations for the patientsleaving the scene. Requests for the provision of additional medical or public health resources to thescene are also the responsibility of the Site Medical Commander.
Responsibilities include: Obtain briefing from the Health Incident Controller; Develop the medical and or public health operational objectives of the site management plan in
conjunction with the Health Incident Controller; Oversee the implementation of the site management plan; Coordinate with the site commanders from all other agencies especially ambulance; Provide overall control and coordination of the primary triage area(s) with particular respect to
triage, transport and dispersal ; Coordinate with other site commanders where necessary tovary the SOP’s to ensure optimum safety for both patients and emergency personnel;
Brief and allocate (according to the site management objectives) arriving medical or publichealth personnel within the triage, treatment and dispersal framework;
Determine needs and request additional medical or public health resources; Report information about special activities events and occurrences to the Health Incident
Controller; Liaise with the ambulance transport officer to ensure appropriate provision of transport
services; Determine the level of escort required for patients en route to hospital Liaise with the Health Incident Controller to ensure appropriate destinations are found for all
patients; Maintain frequent communications with hospitals either directly or via the Health Incident
Controller to ensure hospitals have accurate information with which to plan; and Maintain a log of all activities.
Planning Officer
The Planning Officer is responsible for the collection, evaluation, dissemination and use ofinformation about the incident and status of resources.
Responsibilities include: Obtain briefing from Health Incident Controller; Negotiate with Health Commander the allocation and deployment of initial response
personnel as appropriate; Establish information requirements and reporting schedules for all involved in the
management of the incident; Establish as required information gathering and planning elements – for example: Weather collection system; Organise specialist advice; and HR requirements to maintain continued services or response; Supervise/prepare incident management plan; Assemble information on alternate strategies; Identify use of specialised resource/s; Provide periodic predictions on incident potential; Provide management support to the Health Incident Controller; Consider safety and welfare implications for all personnel during and Maintain log of all activities
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Logistics Officer
The Logistics Officer is responsible for providing facilities, services and material in support of theincident management. The Logistics Officer participates in the development and implementation of themanagement plan and manages the functions within the logistics section.
Responsibilities include: Obtain briefing from Health Incident Controller Plan organisation of the logistics section; Allocate logistics work tasks; Participate in preparation of management plan Identify medical and support requirements for planned and expected operations; Coordinate
and process requests for resources; Estimate logistic needs for continuing operational response; Provide advice to IMT on current capabilities; and Maintain log of all activities with a particular emphasis on any logistic requirements that may
have financial/funding implications.
Liaison Officer
The Liaison Officer reports to the Health Incident Controller and is the point of contact for assisting andliaising with other agency representatives.
Responsibilities include: Obtain briefing from Health Incident Controller Provide a point of contact for assisting agency representatives Identify other agency liaison officers including their contact / communication link and location; Respond to requests from health incident personnel for inter-organisational support; Monitor
incident response and operations for potential inter-organisational problems; and Maintain log of activities.
Media and Communication Officer
The Media and Communication Officer is responsible for providing and coordinating media response,internal and external communication requirements, and stakeholder relations in support of the incidentmanagement. The Media and Communication Officer participates in development and implementation ofthe management plan.
Responsibilities include:
Media and communication response strategy in partnership with the incident management team,MHHSs, units and senior executives;
Develop the overall media and communication response category in partnership with the incidentmanagement team, MHHSs, units and executives;
Manage and coordinate all internal and external communication, media in and stakeholder relations outputs. Provide strategic internal and external communication and stakeholder relations advice to the
Director-General, senior executives and Incident Controller; Provide direction to media andcommunication support staff.
Act as media and communication liaison key conduit with the Ministers office.
Recommended