Effective:
This information is available in alternative formats upon request
Page 1 of 61
Effective: 1 October 2014
WACHS KIMBERLEY
Derby Hospital
TITLE: CODE YELLOW - BUSINESS CONTINUITY PLAN
AUTHORISATION This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction. This plan has been formally endorsed by the following personnel (and approved by the Regional Director) as the Standard Operating Procedures to be followed in the event of such a resource failure or malfunction. The BCP should link in with existing Hospital Emergency/Disaster Procedures, and as such, should be read in conjunction with those document to make sure all staff are familiar with the procedures for both external and internal emergencies/disasters should the resource failure escalate, or be of significant magnitude as to effect the functioning of the Hospital and risk patient care. Recommended Bec Smith
Operations Manager Hospital Disaster Coordinator
Dated Approved
Kerry Winsor Regional Director, WACHS Kimberley
Dated VERSION CONTROL Amendment Entered Version
No. Page Number Date Signature Date
This information is available in alternative formats upon request
DISTRIBUTION LIST This plan has been distributed to the following:
Name Organisation Position/Function Kerry Winsor WA Country Health Service Regional Director - Kimberley Ben Watty WA Country Health Service A/Regional Facilities Manager -
Kimberley Dave Dench WA Police Officer in Charge - Derby Stephen Gash Shire Derby West Kimberley Chief Executive Officer Elsia Archer Shire Derby West Kimberley President – LEMC Chair GLOSSERY OF TERMS Business continuity Management Business Continuity Management (BCM) is a discipline that prepares an organisation for the unexpected. It is a management process that provides the framework for building the resilience to business and service interruption risks, responding in a timely manner to ensure continuity of critical business activities, and ensuring the long term viability of the organisation following a disruptive event. Business continuity plan A business continuity plan (BCP) is, in effect, a treatment plan for certain risks, the consequences of which could disrupt core functions. The plan outlines the actions to be taken and resources to be used before, during and after a disruptive event to ensure the timely resumption of critical business activities and long term recovery of the organisation. Critical business activity Although there are a wide range of business activities that are provided to internal and external customers, identification of critical business activities allows organisations to identify what businesses are essential. This allows prioritisation of services in the event of a service-level disruption to the organisation’s daily operations. Contingency maximum operating length time The contingency maximum operating length time determines how long the contingency or intervention can continue for. In some circumstances, the time may be finite, whereas in other circumstances, the contingency can continue indefinitely. Contingency plans For the purpose of this document, contingency plans refer to plans developed by the nominated person for each critical function areas which include actions to be taken in the event of a resource/s failure due to any cause. These plans are developed locally and are to include responses at ward level, support services and management/executive level.
Page 2 of 72
This information is available in alternative formats upon request
Disaster An event, actual or imminent, which endangers or threatens to endanger life, property or the environment, and which is beyond the resources of a single organisation to manage or which requires the coordination of a number of significant emergency management activities. NOTE: The terms "emergency" and "disaster" are used nationally and internationally to describe events which require special arrangements to manage the situation. "Emergencies" or "disasters" are characterised by the need to deal with the hazard and its impact on the community. The term "emergency" is used on the understanding that it also includes any meaning of the word "disaster". Disaster plans For the purposes of this document, disaster plans refer to plans developed by the nominated person responsible for maintaining up to date plans, which include actions to be taken in the event of a major failure or disaster. Every hospital and health service should have such a plan. Hospital health coordinator A Hospital Health Coordinator (HHC) is a person designated by the hospital executive to be the hospital coordinator for the purposes of coordinating the hospital response in an emergency. Each hospital will provide a rostered HHC who is available 24 hours per day for:
• being the contact position to receive/give the initial notification that the hospital is involved in a major incident/disaster.
• commencing a notification process to alert other key hospital disaster stakeholders
• monitoring the overall hospital response to the situation • assuming overall command and control of the hospital's general resources and
management of its responses during the time the hospital disaster plan is activated, be it for an internal disaster or as a response to an external disaster.
Each hospital will have an appropriate system to enable this notification process to be conducted in a timely manner, as per Operational Directive 0302/10. Impact The impact defines what the effect will be if the critical business activity is lost or not available. In strategic terms, many impacts may be defined ambiguously, such as loss of assets or denial of access. This BCP will focus upon clinical and business related impacts. Maximum Acceptable Outage Maximum Acceptable Outage (MAO) is a measurement concept that enables stakeholders to make an informed decision on how long a particular critical business activity can be disrupted before the consequences become unacceptable.
Page 3 of 72
This information is available in alternative formats upon request
On-Call Clinical Officer The On-Call Clinical Officer (OCCO) (formerly the Hospital Emergency Operations Centre Coordinator [HEOC Coordinator]) is an officer with a clinical background who, on the authority of the State Health Coordinator (SHC), oversees the coordinated use of hospital resources in WA Health. On-Call Duty Officer The On-Call Duty Officer (OCDO) is the single point of entry into WA Health for notifications of all incidents or issues, including communicable diseases, environmental health, hospital service continuity and incident notification. Regional Health Disaster Coordinator A Regional Health Disaster Coordinator (RHDC) is a person designated by the CEO of the WA Country Health Service (WACHS), on recommendation by the Regional Director, to be the Regional Health Coordinator of a designated regional health service in accordance with WACHS Disaster Management Arrangement Policy 001, for the purposes of coordinating the regional health response in a major incident emergency. Relevant stakeholders Relevant Stakeholders are the key contacts or key stakeholders that must be considered in the event that State-level interventions and contingencies are implemented. Relevant stakeholders are critical to the success of the employed contingency.
ABBREVIATIONS BCM - Business Continuity Management BCP - Business Continuity Plan CEO - Chief Executive Officer COO - Chief Operating Officer CSSD - Central Sterile Supply Department CUA - Common Use Agreements DEMC - District Emergency Management Committee DFES - Department of Fire and Emergency Services DON - Director of Nursing DPMU - Disaster Preparedness and Management Unit DRP - Disaster Recovery Plans HCN - Health Corporate Network HIN - Health Information Network HHC - Hospital Health Coordinator HRT - Hospital Response Team ICT - Information Communication Technology LEMC - Local Emergency Management Committee LEOC – Local Emergency Operations Centre LOS - Length of Stay LTI - Lost-time Injury MAO - Maximum Acceptable Outage MCI - Mass Casualty Incident MOU - Memorandum of Understanding OCCO - On-Call Clinical Officer OCDO - On-Call Duty Officer
Page 4 of 72
This information is available in alternative formats upon request
OCMO - Office of the Chief Medical Officer OD - Operational Directive PABX - Private Automatic Branch eXchange RFDS - Royal Flying Doctor Service RHDC - Regional Health Disaster Coordinator SHBCP - State Health Business Continuity Plan SHC - State Health Coordinator SHEF - State Health Executive Forum SHICC - State Health Incident Coordination Centre SJA - St John Ambulance SLA - Service Level Agreement SOP - Standard Operating Procedure WA - Western Australia WACHS - WA Country Health Service WWC - Working With Children
PART ONE - INTRODUCTION
1. PREAMBLE The Public Sector Commissioner’s Circular 2009-19 states “all public sector bodies must practice risk management, regularly undertake a structured risk assessment process to identify the risks facing their organisations, be able to demonstrate the management of risks and where appropriate be able to have continuity plans to ensure that they can respond to and recover from any business disruption.” The Western Australian Department of Health (WA Health) requires all hospitals and support services to have in place Business Continuity Plans (BCPs) to ensure continuity of critical business functions in the event of failure or disruption.
2. AIM The aim of the BCP is to provide an organisational platform, which will maximise the efficiency and effectiveness of critical business and clinical functions in the event of localised resource failure. The intentions of the templates are to:
• Provide a check list of critical business and clinical functions and critical support services
• Assist in the preparation of contingency plans in cases of hospital resource failure
• Assist in the preparation of contingency plans in cases of health service wide resource failure
• Assist with the development of a task list for the implementation phase.
Page 5 of 72
This information is available in alternative formats upon request
3. OBJECTIVES
• Understand the environment within which the organisation operates, the existence of constraints and threats to the organisation that could result in a significant disruption (through conducting risk identification and assessment).
• Determine the parts of the business critical to its short and long term success (as part of the business impact analysis).
• Quantify the disruptive impact of these threats on critical business functions and processes, and identify the infrastructure and resources required to enable the organisation to continue to operate at a minimum acceptable level (through the business impact assessment).
• Document the key resources, infrastructure, tasks and responsibilities, required to support these critical business functions in the event of a disruption (developing the business continuity plan).
• Establish processes that ensure the information remains current and relevant to the changing risk and business environments (through maintenance protocols and the ongoing risk management process).
• Ensure that relevant employees, customers, suppliers and other stakeholders are aware of the continuity arrangements and, where appropriate, have confidence in their application (through BCM training and testing of the plans).
4. ASSUMPTIONS
The following assumptions have been made in regards to activating the BCP:
• All hospitals shall develop and document a service continuity plan. • The plan shall be tested and reviewed at the appropriate intervals • The plan shall include intended actions for all foreseeable disruptions to the
continuity of services provided by the hospital: o For which planning is possible. o Prioritised first by the impact of the disruption on service delivery (most
severe being the highest priority). • The plan integrates with the plans of other health service plans and with the
SHBCP, the result being a whole of health service continuity initiative. • The plan shall identify the extent of the hospital’s intended actions for each
foreseeable disruption. The extent of the hospital’s intended actions is to be determined in consultation with the Disaster Preparedness and Management Unit (DPMU) prior to finalisation of the plan.
• Where the hospital’s service continuity capabilities are insufficient to manage the disruption, the hospital shall contact the DPMU or SHICC with a request for assistance.
• Granting of a request for assistance results in the activation of the SHBCP and WESTPLAN - Health by the SHC.
• Responsibility for management of the response to the disruption at the site remains with the hospital (and health service). The role of the DPMU is to assist with the response as requested.
• A high level of resilience is expected of the hospital.
Page 6 of 72
This information is available in alternative formats upon request
• All evacuations resulting in internal transfer only shall be managed by the hospital. All evacuations resulting in inter-hospital transfer shall be facilitated by the SHICC.
• The OCDO shall be immediately notified of all disruptions that could foreseeably require the activation of the SHBCP.
• All health services are responsible for ensuring that their staff are familiar with these plans.
• It is acknowledged that not all problems can have contingencies or plans developed and that the management of any incident will be situation specific at the time it occurs.
• The SHICC shall coordinate application of the SHBCP across multiple hospitals as required.
• The DPMU shall develop Memorandums of Understanding (MOU) with agencies and service providers for major critical services (e.g. water and power).
• In the event of a major incident, the principles of WESTPLAN – Health will apply.
5. LEGISLATION AND OTHER STANDARDS Public sector bodies must submit details of their risk management policy assessment processes and continuity plans to Risk Cover in accordance with a schedule that will be provided by the Public Sector Commissioner’s Circular 2009-19 Risk management and Business Continuity Planning. Other standards and guidelines apply to business continuity planning, including:
• Business Continuity Management Guidelines, 2nd Edition (2009) RiskCover, Western Australian Government.
• Australian / New Zealand Business Continuity Management HB 221-2004. • International Risk Management Standard ISO 31000: 2009. • Australian Council on Health Standards EQuIP 5 Standards and Guidelines,
Support Function Standard 2.1 & Corporate Function Standard 3.2 • Standards Australia, AS/NZS HB 292-2006, A Practitioners Guide to Business
Continuity Management. • Standards Australia, AS/NZS HB 221-2004, Business Continuity Management • Standards Australia, AS/NZS HB 293-2006, Executive Guide to Business
Continuity Management. • Standards Australia, AS/NZS 5050: 2010, Business continuity – Managing
disruption-related risk. • Standard Australia AS/NZS 31000: 2009 Risk Management Principles and
Guidelines. • WA Health, Redundancy and Disaster Planning in Health’s Capital Works
Programs (2nd Ed) – January 2012. • Treasurer’s Instruction 825 Risk Management and Security.
Page 7 of 72
This information is available in alternative formats upon request
6. WESTPLAN - Health
In the event of a major incident, the principles of WESTPLAN - Health will apply. This is to ensure the greatest good is done for the greatest number and management of the incident is graduated from local to district to State level as required.
7. GOVERNANCE ARRANGEMENTS The activation of the BCP can only be authorised by the Hospital Emergency Coordinator and/or the Regional Health Disaster Coordinator. Individual hospitals, health services are responsible for maintaining their individual disaster plans and ensuring they are congruent with the SHBCP. They are also responsible for ensuring that there is a contact person (i.e. HHC) available 24 hours per day should the RHDC or SHC require their assistance.
8. AUTHORITY AND PLANNING RESPONSIBILITY
The development, implementation and revision of the BCP is the responsibility of the Hospital Health Coordinator in consultation with Regional Emergency & Disaster Management Committee.
Page 8 of 72
This information is available in alternative formats upon request
PART TWO – OPERATIONAL MANAGEMENT
2. ROLES, RESPONSIBILITIES AND AUTHORITIES
Emergency management requires a structure to coordinate all actions needed to deal with incidents or disasters. This section outlines the roles and responsibilities of those persons implementing the BCP.
2.1 Regional Health Disaster Coordinator The RHDC has an operational role in rural/remote areas and is responsible to the SHC. The RHDC(s) responsibilities are to:
• Notify the SHC, Regional Director, Chief Operating Officer (COO) and Chief Executive Officer (CEO) of the Western Australian Country Health Services (WACHS) of emergency management and/or business continuity plan activation.
• Represent the health district at District Emergency Management Committees (DEMC).
2.2 Hospital Health Coordinator HHCs are responsible to the RHDCs during a MCI for:
• Provision of the hospital’s available resources. • Assuming overall command and control of the hospitals' general resources and
management of its responses. • Determining when it is appropriate to return to normal operations within the
hospital and managing the recovery phase. • Representing the hospital at Local Emergency Management Committee
(LEMC) meetings. • Maintenance of the hospital disaster plan (however titled). • Other duties, as requested.
2.3 Department heads/business managers and other nominated staff
• Responsible for ensuring that the business continuity management process is undertaken within their departments / divisions.
2.4 All Staff (including contract and agency staff)
• Responsible for familiarising yourself with the local Business Continuity Plan for your workplace. Business Continuity Plans outline contingencies to respond to a local critical resource failure and provides initial response guidance to ensure continuing support to patient care whilst ensuring the safety of all people at a workplace.
Page 9 of 72
This information is available in alternative formats upon request
3. STAGES OF ACTIVATION The BCP will normally be activated in stages. In an impact event, these stages may be condensed with stages being activated concurrently.
• Stage 1 – Alert - The alert stage is activated when advice of an impending emergency or failure is received or, when following the occurrence of an event, it is unclear as to whether a Regional response is required. During this stage, the situation is monitored to determine the likelihood and nature of the health service’s response
• Stage 2 – Standby – The standby stage is activated when information received is sufficient to warrant preparatory activities in readiness for a response.
• Stage 3 – Response - The response stage is activated when a local emergency response is required and BCP procedures are enacted.
• Stage 4 – Stand Down - The stand down stage is activated when a response is no longer required. Recovery activities are undertaken.
4. DEBRIEFING De-briefing should be conducted immediately after each enactment of the plan, be it either a real event or an exercise to identify lessons learned and ways for improving the BCP. A report outlining the outcomes of the event/exercise, lessons learned and recommendations for improvements should also be prepared and presented to regional executive for endorsement. 5. TRAINING Hospital sites are responsible for ensuring:
• Training of staff on how and when the plan is the be used, • Exercising or rehearsing the plan to ensure that staff are indeed able to execute the
plan, and • Putting in place a maintenance process to keep the plan current and relevant.
Training To ensure that BCM capability continues to reflect the nature, scale and complexity of the organisation it supports, it must be understood by all staff and stakeholders. The primary objective of training is to ensure that the importance of BCM is understood by all staff in the health service and they are aware of their roles and responsibilities during an emergency or crisis situation. General staff awareness training is to be delivered to all staff incorporated into the inductions programme. This should cover topics such as;
o an overview of what BCM, o why is BCM important to the organisations, o what is the staff’s role in an emergency, o what should the staff do if the BCM plan is invoked, and o what are the emergency contact numbers.
More specialised and targeted training may be provided for Hospital Health Coordinators and Senior Managers who have specific BCM responsibilities.
Page 10 of 72
This information is available in alternative formats upon request
Exercising A business continuity plan is of little use until it can be validated that it is actually workable in the event of a business interruption. Exercising the plan helps to:
• Ensure the components of the plans are complete and current; • Provide comprehensive practice for staff involved in recovery activities; • To ensure awareness of key suppliers and partners of the Agency’s reliance on
them in the event of a plan invocation; • Identify where recovery processes failed and the actions and costs required to
resolve; and • Satisfy auditors and insurers with documented and tested plans.
Exercise Regimes:
Test Type Activities Desktop review Normally conducted as one of the first plan ‘tests’, it involves a
physical examination and review of the plan documentation. Aims to ensure that: • Plan document is complete and relevant to the expressed
business needs (operational and strategic). • The relevance and currency of the risk assessment, business
impact assessment and continuity plan are tested. • Inconsistencies in logical flow, resources allocations or conflict
between individual plans are recognised. Desktop scenario test
Involves a desktop walkthrough of the plan(s), with discussion guided by the use of one or more potential scenarios. The activities are based around a series of questions and answers relating to the deployment of the plans in response to changing issues in the scenarios.
Notification and call-out communications test
Activities are based around the verification of the accuracy, currency and utility of notification and call-out lists, call out trees (who you have to call) and deputised positions.
Live scenario tests
Can be conducted as a limited activation (narrow/specific scenario and/or targeted areas of the organisation) up to a full scale activation of al continuity arrangements for the organisation.
Business recovery tests
Involves the closing down or removal of access to infrastructure or resources and test the capability of recovery measures.
Desired Outcome Plan Activation Plans are activated according to the nature of the disruption and in an
appropriate authorised manner. Governance issues
Post activation governance requirements are identified as part of the response plan and are managed during after the response is activated and stood down.
Page 11 of 72
This information is available in alternative formats upon request
An Exercise Plan should be prepared and approved by management prior to any major exercises. The Exercise Plan outlines the objectives and scope of the exercise, roles and responsibilities, assumptions and parameters, criteria for assessing the outcomes, and logistics aspects of the exercise, such as date, time, venue, transportation, and technical support. A training and testing worksheet is located at appendix 1. Maintenance A maintenance programme ensures that the business continuity plan remains current and relevant, ready to handle any crisis despite the constant change and dynamic environment that all organisations experience. It should be viewed as part of normal change management processes rather than be a separate structure. Maintenance will need to be undertaken:
• When new processes are added or existing processes are modified or removed; • When there is a major change to the Agency’s technology or location; • After the Agency has performed an exercise; • After an audit where gaps have been identified and recommendations for
improvements made; and • In accordance with the Agency’s BCM maintenance programme.
Plan Component Maintenance Timeframe
BCM Policy Reviewed and updated bi-annually Business Impact Analysis Reviewed and updated once a year or when there are any
significant changes to the business Business Continuity Plan Reviewed and updated once a year or when there are any
significant changes to the business Contact Lists Reviewed and updated every 3 months
6. CONTACT DETAILS A listing of key positions and their contact details are given in PART 3.
This document can be made available in alternative formats on request for a person with a disability
Contact: Operations Manager (B.Smith) Directorate: Operations TRIM Record # ED-CO-15-6124
Version: 1.00 Date Published: February 2014
Page 12 of 72
Effective:
This information is available in alternative formats upon request
Page 13 of 61
Effective: 1 October 2014
IMPACT RATING DEFINITIONS Impact ratings have been included to describe the severity of the service disruption based on both business and clinical outcomes. The identification of the disruption impact rating allows for the prioritisation of contingency to occur. Disruption Impact Table
LEVEL 1 2 3 4 5
IMPACT CATEGORIES
CODE Insignificant Minor Moderate Major Catastrophic
HEALTH IMPACT on PATIENT (s)
HP Increased level of care (minimal).
No increase in length of stay.
Not disabling.
Increased level of care (minimal).
Increased length of stay (up to 72 hours).
Recovery without complication or permanent disability.
Increased level of care (moderate).
Extended length of stay (72 hours to one week).
Recovery without significant complication or significant permanent disability.
Increased level of care (significant).
Extended length of stay (greater than one week).
Significant complication and/or significant permanent disability.
Death, permanent total disability.
ALL SENTINEL EVENTS.
HEALTH IMPACT ON STAFF OR OTHERS
HS First aid or equivalent only.
Routine medical attention required. Max 1 week’s incapacity/time lost. No disability.
Increased level of medical attention required. 1 week to 1 month incapacity/time lost. No significant permanent disability.
Severe health crisis and/or injuries, Prolonged incapacity or absence 1 month +. Significant permanent disability.
Death or permanent total disability.
This information is available in alternative formats upon request
CRITICAL SERVICES INTERRUPTION
CS No material disruption to dependent work.
Short-term temporary suspension of work. Backlog cleared in day. No public impact.
Medium-term temporary suspension of work. Backlog requires extended work or overtime or additional resources to clear. Manageable impact.
Prolonged suspension of work. Additional resources, budget, Management assistance required. Performance criteria compromised.
Indeterminate prolonged suspension of work. Impact not manageable. Non-performance. Other providers appointed.
PERFORMANCE TO BUDGET (Over or underspend)
PB Less than 1% temporary variance.
1% to 2% temporary variance.
More than 2% up to 5% temporary variance.
More than 5% to 10% variance NOT recoverable within the financial year.
More than 10%variance NOT recoverable within the financial year, or being unable to pay staff, creditors or finance critical services.
FINANCIAL LOSS
FL Less than $5,000. $5,000 to less than $100,000.
$100,000 to less than $3M.
$3M to less than $20M.
$20M +.
ORGANISATIONAL OBJECTIVES OR OUTCOMES
OO Little impact. Inconvenient delays.
Material delays. Marginal under achievement of target performance.
Significant delays. Performance significantly under target.
Non-achievement of objective / outcome. Total performance failure.
REPUTATION AND IMAGE DAMAGE
RI Non-headline exposure. Not at fault. Settled quickly. No impact.
Non-headline exposure. Clear fault. Settled quickly by Departmental response. Negligible impact.
Repeated non-headline exposure. Slow resolution. Ministerial enquiry / briefing. Qualified Accreditation.
Headline profile. Repeated exposure. At fault or unresolved complexities impacting public or key groups. Ministerial involvement. High priority recommendation to preserve accreditation.
Maximum multiple high-level exposure. Ministerial censure. Direct intervention. Loss of credibility and public / key stakeholder support. Accreditation withdrawn.
(This table has been adapted from Office of Safety and Quality, 2009, ‘Integrated Clinical and Corporate Risk Analysis Tables and Evaluation Criteria (2009)’, Department of Health, Government of Western Australia.)
Page 14 of 72
Effective:
This information is available in alternative formats upon request
Page 15 of 61
Effective: 1 October 2014
7. Contingency Plans for Hospital Wide Resource Failure 7.1 Electricity Supply Failure Description: Failure of supply of electricity to whole hospital Impact Rating: Extreme Consequences of resource failure: Inability to supply normal services to all sites. Contingency strategy options: Emergency hospital power generation Consider service delivery levels, i.e. Revert to emergency cases only (i.e. no elective
procedures) Consider where patient cannot be discharged, the need to relocate patients to other hospitals Contact Hire companies for standby generators: see Location/Providers below. How long can operations continue in contingency mode: 2 - 3 Weeks – if hospital generator working 1 days – without power Trigger event/date to invoke the Business Continuity Plan: Electricity supply disruption/failure. Responsibility for implementing this strategy: District Manager Director of Nursing Maintenance Manager. Criteria for returning to normal operating mode: Resumption of electricity supply of a period greater than 15 minutes. Can this strategy be tested if so how: Yes, planned interruption to normal supply, run on emergency generation Location/Providers Coates Hire for generators: 9192 1080 Energy Applications – generator repair: 9192 1994 Broome Diesel and Hydraulic – generator repair mechanical: 9192 1330 Outback Electrical Derby: 0419 914 088 Wattnow Electrical Derby: 0488 410 497
Effective:
This information is available in alternative formats upon request
Page 16 of 61
Effective: 1 October 2014
7.1.1 Electricity Supply Schedule Problem Impact Contingency Action/Task Start date End date Responsibility Electricity Failure Inability to supply
normal services to all sites
Emergency power generation
Ensure emergency generator supply to site
At point of failure 15 mins after resumption of normal power supply
Maintenance Manager
Ensure 4500 L fuel available on site
Continuous Continuous Maintenance Manager
Ensure essential appliances are connected to essential power outlets
At point of failure 15 mins after resumption of normal power supply
Maintenance Manager
Director of Nursing
Transfer patients out
Identify Patients for transfer
When contingency fails
Normal supply Senior Medical Officer
Director of Nursing Use alternate
emergency generator
Liaise with SES and Equipment Hire Company for priority use of generator
When contingency fails
Return to normal service
Operations Manager /Regional Director
Contingency failure
Close Hospital
Transfer patients out & close hospital
Contingency failure
Normal supply Operations Manager / Regional Director
Staff Education
Educate staff on contingency arrangements
On going Director of Nursing Maintenance
Manager
This information is available in alternative formats upon request
7.2 Air Conditioning Service Failure Description: Failure of air-conditioning not due to power failure in: 28 units in general ward 10 units in paediatric area 13 units maternity ward 9 units in kitchen and staff dining room Chilled water system to rest of Hospital Impact Rating: Very high Consequences of resource failure: Unable to regulate temperature and environment – patient and staff discomfort Contingency strategy options: Natural Ventilation – use fans and open windows Transfer emergency procedures to other facilities Discharge or transfer patients How long can operations continue in contingency mode: Operating Theatres – unable to continue. Rest of DHS – indefinite, depending on ambient conditions and comfort levels. Trigger event/date to invoke the Business Continuity Plan: Air Conditioning failure Responsibility for implementing this strategy: Operations Manager Director of Nursing Business Manager Maintenance Manager Criteria for returning to normal operating mode: Restoration of air conditioning function Can this strategy be tested; if so how: Isolate air conditioners Locations/Providers Maintenance Department ext 325 Maintenance Manager: 0429 109 010 Derby Refrigeration & Air-conditioning services: 9193 1729 QAL Refrigeration: 0418 873 593
Page 17 of 72
This information is available in alternative formats upon request
7.2.1 Air Conditioning Service Schedule
Problem Impact Contingency Action/Task Start date End date Responsibility Air Conditioning Failure Unable to
regulate temperature and environment
Instigate repair Call Maintenance Manager
When failure occurs
15 mins after Return of service
Director of Nursing Maintenance
Manager
Use natural ventilation / open windows / doors
Distribute fans from Maintenance Store
When failure occurs
15 mins after Return of service
Director of Nursing Maintenance
Manager
Use fans Determine priority sites for use of fans
When failure occurs
15 mins after Return of service
Director of Nursing Maintenance
Manager
Page 18 of 72
This information is available in alternative formats upon request
7.3 LPG Supply Description: Failure of Supply of Liquid Petroleum Gas due to no deliveries available to replenish supply.
LPG used in: Kitchen/Laundry Boiler Plant Room
Impact Rating Very High Consequences of resource failure: Unable to run cookers, dryers and hot water boiler. Can run on supply tanks for estimated 4 weeks. Contingency strategy options: Install temporary bottled supply to each outlet. Available from Kleenheat Gas: See Location/Providers below How long can operations continue in contingency mode: indefinitely Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Notification from supplier of loss of continuous supply Mechanical damage Regulator failure Responsibility for implementing this strategy: Operations Manager Director of Nursing Business Manager Maintenance Manager Criteria for returning to normal operating mode: Notification from supplier that supplies have returned to normal. Damaged equipment repaired or replaced Replentished supply Can this strategy be tested if so how: No Locations/Providers: Kleenheat Gas for bulk supplies 9192 3733 Kleenheat Gas for bottled supplies 9192 3733 Elders Derby: 9191 1808 Mobile: 0427 991 129
Page 19 of 72
This information is available in alternative formats upon request
7.3.1 LPG Supply Schedule Problem Impact Contingency Action/Task Start date End date Responsibility Bulk LPG Supply
Loss of bulk LPG supply
(and see other impacts below)
Emergency refill Or get bottled gas
delivered to site
Identify essential sites for gas rationing
Loss of supply Return of normal supply
Operations Manager Maintenance
Manager
Mechanical damage Regulator failure
Get bottled gas delivered to site
Re-order from Kleenheat Bulk
Order from Kleenheat local
When bulk gas is unavailable
Return of normal supply
Operations Manager Maintenance Manager
Unable to do use laundry dryer
Access other clothes drying facilities in town
Source alternative commercial dryers
Annual Return of normal supply
Support Services Manager
Rationalise use of linen
Without compromising infection control principles, reduce the amount of clean linen needed (e.g. Derby)
Annual agreement with Derby Health Services
When supply is compromised
Return of normal supply
Director of Nursing Support Services
Manager
Arrange for linen supplies from other regional health services
When previous contingencies fail
Return of normal supply
Support Services Manager
Unable to use stove in kitchen
Access other cooking facilities
Identify other means of cooking e.g. microwave
When supply is compromised
Return to normal service
Maintenance Manager/ Cook
Identify other commercial kitchens in the area e.g. hotels, restaurants
Annual agreement with commercial kitchen
Normal supply Support Services Manager
Alternate food supplies Annual agreement with In-flight Catering
Return to normal service
Support Services Manager
Purchase reheatable prepared meals
Source and cost meals
Return to normal service
Support Services Manager
Staff Education Educate staff on contingency plans
Orientation Ongoing Staff Development Officer
Page 20 of 72
This information is available in alternative formats upon request
7.4 Medical Gases Description: Failure of bulk supply of Oxygen Failure of both bulk and reticulated bottled supply of Oxygen No Bottles Failure of bottled Nitrous Oxide. Impact Rating: Extreme Consequences of resource failure: Failure of the ongoing supply of medical gases by external suppliers would severely interrupt
the ability to conduct surgery and treat critically ill patients. Contingency strategy options: Stockpile gas supplies Have alternate suppliers established and contact numbers recorded. How long can operations continue in contingency mode: Failure of bulk supply: Indefinite depending on bottled supply Failure of bottled supply: Cannot continue Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Notification from supplier of loss of continuous supply Responsibility for implementing this strategy: Operations Manager Senior Medical Officer Director of Nursing Business Manager Maintenance Manager Criteria for returning to normal operating mode: Notification from supplier that supplies have returned to normal. Can this strategy be tested if so how: Test alarms and changeover methods Locations/Providers: BOC Gases, Streeter and Male Derby Building Supplies: 9191 1537 Mobile: 0419 950 903
Page 21 of 72
This information is available in alternative formats upon request
7.4.1 Medical Gases Schedule Problem Impact Contingency Action/Task Start date End date Responsibility Loss of medical gas supply Bottles only
Unable to supply medical gases for therapeutic use
Stockpile bottled supply of medical gases onsite
Increase stock for the cyclone season.
Impress system check weekly.
Ensure adequate local supplies
Identify priority sites for use of medical gases (incl. home O2 supply)
When supply compromised
Annual agreement with BOC to stockpile offsite
Return of supply
Director of Nursing Senior Medical Officer Support Services
Manager
Estimate usage of medical gases per week
Annually Senior Medical Officer Director of Nursing Maintenance Manager
Stockpile for at least two weeks without supply
Continuous Business Manager and Maintenance Manager
Distribute bottled gases to priority sites
When supplies are low
Normal supply
Business Manager and Maintenance Manager
Priority use of medical gases
Identify patients for priority use
When supplies are low
Normal supply
Senior Medical Officer DON
Transfer patients out
Identify patients for transfer
When supplies are low
Normal supply
Senior Medical Officer
Staff Education Educate staff on medical gas use and contingency
Orientation Ongoing Director of Nursing Senior Medical
Officers Business Manager
and Maintenance Manager
Page 22 of 72
This information is available in alternative formats upon request
7.5 Motor Vehicle Fuels Description: Loss of supply of Petrol and Diesel for Health Service vehicles. Impact Rating: Medium Consequences of resource failure: If suppliers have difficulty with pumps etc. this will impact on the Health Service. Contingency strategy options: Have all vehicles full when impending shortage is anticipated Transfer fuel from non essential to essential vehicles if supplies become severely diminished How long can operations continue in contingency mode: Indefinite with use of town suppliers – taxi etc. Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Loss of supply of Petrol/Diesel. Responsibility for implementing this strategy: Operations Manager Director of Nursing Business Manager Maintenance Manager Criteria for returning to normal operating mode: Notification from supplier that supplies have returned to normal. Can this strategy be tested if so how: No Locations/Providers: 4500 L Diesel tank on hospital campus BP Colac & Shell Service Stations: 0409 302 175 / 0400 218 835 BP Reliance: 9191 1383
Page 23 of 72
This information is available in alternative formats upon request
7.5.1 Motor Vehicle Fuels Schedule Problem Impact Contingency Action/Task Start date End date Responsibility Motor Vehicle Fuels Loss of supply,
inability to transport
Vehicles at capacity fuel level
Ensure all vehicles full of fuel
When there is an anticipated shortage
Return to normal supply
Business Manager
Ration fuel to essential vehicles
Transfer fuel to essential vehicles
Loss of supply Normal supply Operations Manager
Business Manager
Staff education Educate staff on contingency
Orientation Ongoing Business Manager
Cut back on transport
Identify essential vehicles
When there is an anticipated shortage
Return to normal supply
Business Manager
Use hospital diesel store
Ensure tank full Continuous Business Manager
Maintenance Manager
Page 24 of 72
This information is available in alternative formats upon request
7.6 Sewerage Description: Failure of sewerage disposal systems (town sewerage system) Impact Rating: Extreme Consequences of resource failure: Toilets, drains will stop flowing creating health hazard. Build up of waste will prevent patient treatment Contingency strategy options: Hire PortaLoos Relocate patients Contact local plumber Seek advice from local Government authority – Derby Shire Seek advice from Public Health Unit How long can operations continue in contingency mode: Less than 1 week Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Advice from local authority (local council) of failure of systems Responsibility for implementing this strategy: Operations Manager Director of Nursing Business Manager Maintenance Manager Criteria for returning to normal operating mode: Reinstatement of sewerage facilities/services Can this strategy be tested if so how: No Locations/Providers: Kimberley Hire Derby: 9191 1635 Mobile: 0419 923 169 Water Corp: 131375 Local Manager: 0417 182 405 Derby Shire Director of Engineering Services: A/H Emergency: 0418 922 415
Page 25 of 72
This information is available in alternative formats upon request
7.6.1 Sewerage Schedule Problem Impact Contingency Action/Task Start date End date Responsibility Sewerage service Unable to dispose
of waste products Alternate toilet
facilities Identify alternate
toilet facilities / devices i.e. portaloos from Wreck Air Hire.
Annual Agreement
Normal service Business Manager Maintenance
Manager
Identify amount of alternate facilities / devices needed and priority use areas
When resources fail
Business Manager Maintenance
Manager
Source supply / cost of alternate devices
Annually Business Manager
Develop protocols for patient use of alternate facilities
Updated annually Director of Nursing
Initiate use of alternate facilities / devices
Loss of all facilities
Normal service Emergency Co-ordinator
Director of Nursing Staff education Educate staff on
contingency plans Orientation Orientation Staff Development
Officer Failure of
contingency Close hospital Transfer patients
out, close hospital Loss of all
facilities Normal service Emergency Co-
ordinator
Page 26 of 72
This information is available in alternative formats upon request
7.7 Vehicles and Transport Description: Loss or failure of motor vehicles, Impact Rating: Medium Consequences of resource failure: • Comunnity Health Staff, District Manager and others not able to provide out-reach services Contingency strategy options: Source alternative vehicles (ie. contractors) How long can operations continue in contingency mode: Indefinite Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Fuel shortage Mechanical breakdown/failure Theft of vehicles Damage Responsibility for implementing this strategy: Operations Manager Business Manager Director of Nursing Criteria for returning to normal operating mode: Resource loss issues resolved Vehicles repaired, replaced Can this strategy be tested if so how: No Locations/Providers: BP Colac Service Station: 0409 302 175 / 0400 218 835 Kimberley Car Hire: 9191 1222 / 0447 911 222 Hertz at Broome International Airport: 9192 1428
Page 27 of 72
This information is available in alternative formats upon request
7.7.1 Vehicles and Transport Schedule
Problem Impact Contingency Action/Task Start date End date Responsibility Vehicles / Transport loss Field staff unable
to provide out-reach services.
Provide services to communities who need ongoing services
Identify vehicles needed for transport
Continuous Return to normal service
Business Manager
Identify who needs ongoing services
When transport compromised
Return to normal service
Business Manager
Initiate use of alternate vehicles
Loss of vehicles Normal service Business Manager
Staff education Educate staff on contingency
Orientation Ongoing Staff Development Officer
Page 28 of 72
This information is available in alternative formats upon request
7.8 Water Supply Description: Loss of scheme water supply to all facilities Failure of hospital bore Impact Rating: Extreme Consequences of resource failure: Cannot provide health service Contingency strategy options: Hospital has 1 bore pump on site – Maintenance Manager has the capacity to hook into the
hospital system via a reticulation system Relocate patients to an unaffected site Contact local supplier- to bring in bottled water. Distribute bottled drinking water – 200 litres kept in Plant Room; distribute to departments. Buy bulk water in tanker from contractors – McCorry Brown see below. How long can operations continue in contingency mode: 20,000 L tank = 48 hours for washing, flushing only (Not for drinking) If bore fails, 1 day's supply only for washing and flushing Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Failure of water supply Responsibility for implementing this strategy: Operations Manager Director of Nursing Business Manager Maintenance Manager Criteria for returning to normal operating mode: Rectification of water supply – supply back to normal Can this strategy be tested if so how: Yes – storage facilities can be tested to see how long they will last. Locations/Providers: Emergency water bore pump on hospital site Water Corporation. Phone: 13 13 75 Local Manager: 0417 182 405 BEP Derby: 9191 1138
Page 29 of 72
This information is available in alternative formats upon request
7.8.1 Water Supply Schedule Problem Impact Contingency Action/Task Start date End date Responsibility Loss of scheme Water supply Loss of water
supply for general use
Can use reticulation water for washing flushing, and staff hygiene
Use bottled water for drinking, food preparation
Use bore pump to pump water to reticulation tank
Loss of supply Return to normal supply
Business Manager Maintenance
Manager
Source / cost alternate supplies – bottled water
Annually Completed Business Manager
Loss of drinking water for patients / food preparation
Use bottled water supply
Distribute bottled water supply
Loss of supply Service resumed
Business Manager
Contingency Failure
Close hospital Transfer patients out and close hospital
Total loss of supply
Normal supply Emergency Co-ordinator
Staff education Educate staff on contingency
Orientation Ongoing Staff Development Officer
Page 30 of 72
This information is available in alternative formats upon request
7.9 Steam Failure Description: Failure of both steam generators resulting in an inability to operate sterilisers Impact Rating: Very High Consequences of resource failure: Cannot sterilise surgical equipment, materials for sterilising packs Contingency strategy options: Use Broome sterilizing facilities Purchase pre-sterilised instruments Maintain an increased stock level of sterilised instruments Use chemical sterilisation; materials in CSSD How long can operations continue in contingency mode: Using Broome’s services, indefinite Without contingency, cannot continue in operating theatres Without contingency, prioritise health services, reduce load in A&E Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Failure of steam supply Responsibility for implementing this strategy: Operations Manager Director of Nursing Business Manager Maintenance Manager Theatre Manager Criteria for returning to normal operating mode: Rectification of steam supply – supply back to normal Can this strategy be tested if so how: Yes – turn off steam. Locations/Providers: Emergency water bore pump on hospital site Water Corporation. Phone: 13 13 75 Local Manager: 0417 182 405 Athertons 9249 6166
Page 31 of 72
This information is available in alternative formats upon request
7.9.1 Steam Failure
Problem Impact Contingency Action/Tasks Start date End date Responsibility Steam failure Unable to provide
sterilising services Use Broome
sterilizing facilities Make
arrangement with Broome Hospital
On failure of steam supply
Resumption of steam supply
Theatre manager
Purchase pre-sterilised instruments
Locate a supplier of presterilised theatre instruments
On failure of steam supply
Resumption of steam supply
Theatre Manager Business
Manager
Maintain an increased stock level of sterilised instruments
Increase stocked levels of sterilised instruments
Ongoing Ongoing Theatre Manager Business
Manager Stores Manager
Use chemical sterilisation; materials in CSSD
On failure of steam supply
Resumption of steam supply
Theatre Manager
Page 32 of 72
This information is available in alternative formats upon request
7.10 Computer Server Failure Description: Failure of network / servers Impact Rating: Very High/Extreme Consequences of resource failure: No computer network available No access to electronic medical records Unable to order from Central Supply Unable to process financial accounts Unable to create or authorise rosters Unable to process pay Building Management system unable to monitor building services – doors, alarms, air
conditioning, Unable to use communication systems: email Unable to access stored documents on servers: Shared, Nursing, P: drive, other departmental
records held on server. Unable to generate work orders Printers: no access to network printers Contingency strategy options: Switch failure: Use Regional office – ring Kimberley Health Region IT Manager Use modem dial in access from Operations Manager If contingencies above fail: Communications: use phone, fax or in person Medical Records: use hard copies Supply orders: fax or phone, and manual purchase orders Financial accounts: unable to be processed Rosters and Pay: Use dial in system or fax hard copy to Health Corporate Network Building Management system: Use ROAMIO system (palm held unit) Stored documents: Unable to access Work orders: use hard copies Save to disc and print on local printers How long can operations continue in contingency mode: Clinical services: indefinitely Supply services: indefinitely Financial services: hard copy to Perth; use dial in system Rosters & Pay: indefinite Building Management: see Air-conditioning failure. Doors: Alarms: Stored documents: Unable to function
Page 33 of 72
This information is available in alternative formats upon request
Work orders: indefinitely Printing: Indefinitely Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Failure of network servers Responsibility for implementing this strategy: Operations Manager Business Manager Maintenance Manager Kimberley Health Region IT Manager Criteria for returning to normal operating mode: Rectification of server loss – supply back to normal Can this strategy be tested if so how: Yes – power down servers. Locations/Providers: Kimberley Health Region IT manager: Steve Vigh 9194 1605 Mobile 0419 912 301 Derby IT: Mathew George 9193 3279 Mobile 0427 931 446
Page 34 of 72
This information is available in alternative formats upon request
7.10.1 Computer Server Failure Problem Impact Contingency Action/Tasks Start date End date Responsibility Computer server failure
No computer network available
Use Kimberley Health Region switch
Contact Kimberley Health Region IT manager
Loss of server Restoration of server
Operations Manager
Business manager
No access to electronic medical records
Use paper copies Notify no use of electronic copies
Update electronic copies when server becomes available
Record patient details manually
Enter data when system fixed
Access patient ward lists
Loss of server Restoration of server
Health Information Officer
Central Supply unable to purchase
Phone or fax manual purchase orders
Distribute manual purchase orders
Loss of server Restoration of server
Stores Officer
Unable to process financial accounts
Use dial up modem
Fax invoices to an operating network
Loss of server Restoration of server
Business manager
Regional Supply Officer
Unable to create or authorise rosters
Use dial up modem
Fax hard copy to HCN
Departmental managers to inform staff of consequences
Loss of server Restoration of server
Business Manager
All departmental managers
Continued…
Page 35 of 72
This information is available in alternative formats upon request
Problem Impact Contingency Action/Tasks Start date End date Responsibility Building
Management system unable to monitor building services – doors, alarms, air conditioning
Use ROAMIO Connect ROAMIO module where required (maintenance personnel)
Loss of server Restoration of server
Maintenance Manager
Unable to use communication systems: email
Phone, fax, in person
Consider need for communication
Loss of server Restoration of server
All staff
Unable to access stored documents on servers: Shared, Nursing, P: drive, other departmental records held on server.
Unable to use Revert to hard copies of documents
Update electronic versions when server is restored
Loss of server Restoration of server
All staff
Unable to generate work orders
Manual work orders
Distribute manual work orders
Loss of server Restoration of server
Maintenance Secretary
Page 36 of 72
This information is available in alternative formats upon request
7.11 PABX failure Description: Failure of PABX Impact Rating: Extreme Consequences of resource failure: No phone communications throughout hospital No phone communication from hospital to outside Contingency strategy options: 4 phones not on PABX:
General Ward 9191 2191 Emergency Dept 9193 1601 Reception 9191 1517 Maintenance 9191 2972
If contingencies above fail: Use mobile phones Use satellite phones Use 2-way radios How long can operations continue in contingency mode: Indefinitely Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Loss of PABX Responsibility for implementing this strategy: Operations Manager Business Manager Maintenance Manager Kimberley Health Region IT Manager Criteria for returning to normal operating mode: Rectification of PABX – supply back to normal Can this strategy be tested if so how: Yes –disconnect. Locations/Providers: Kimberley Health Region IT manager: Steve Vigh 9194 1605 Mobile 0419 912 301 Derby IT: Mathew George 9193 3279 Mobile 0427 931 446 WACHS Communications Manager: 9222 6492 Mobile 0416 924 605 Norwescom: 91921234 Telstra Business Faults and Technical Support: 132 999 NEC: 131 632
Page 37 of 72
This information is available in alternative formats upon request
7.11.1 PABX Failure Problem Impact Contingency Action/Tasks Start date End date Responsibility PABX failure No internal or
external telephone communications
4 phones not on PABX: one in General Ward, Reception, emergency department and maintenance
Divert main incoming line to Reception Power Fail Phone
Loss of PABX Restoration of PABX
Business Manager
Telstra Supervisor
Clerical Services
Use email communications for correspondence between departments / organisations
Advise of use of email
Loss of PABX Restoration of PABX
Operations Manager
If contingencies above fail:
Use mobile phone communications
Determine essential personel / areas that require a mobile phone during the emergency
Loss of PABX Restoration of PABX
Director of Nursing
Business Manager
Call in all non-essential mobile phones for distribution to essential areas
Loss of PABX Restoration of PABX
Business Manager
Director of Nursing
Continued…
Page 38 of 72
This information is available in alternative formats upon request
Problem Impact Contingency Action/Tasks Start date End date Responsibility Use satellite
phone communications
Determine placement of satellite phones during an emergency
Loss of PABX Restoration of PABX
Business Manager Director of Nursing
Collect & distribute Hospital satellite phones
Loss of PABX Restoration of PABX
Business Manager Director of Nursing
Use 2-way radio communications
Determine placement of 2-way radios during an emergency
Loss of PABX Restoration of PABX
Business Manager Director of Nursing
Liaise with Police to ensure radio link remains open during an emergency
Loss of PABX Restoration of PABX
Business Manager Director of Nursing
Collect & distribute Hospital 2-way radios
Loss of PABX Restoration of PABX
Business Manager Director of Nursing
Maintenance Manager
Broadcast emergency telephone numbers through the media e.g. radio, television
Contact WACHS Communications Manager
Loss of PABX Restoration of PABX
Operations Manager
Use a messenger service system within the health service
Develop protocol detailing an emergency messenger service
Operations Manager
Apoint Messenger Business Manager
Page 39 of 72
This information is available in alternative formats upon request
7.12 Fire System Failure Description: Failure of Fire system: detection and warning Impact Rating: Low (day to day functioning is not impacted Safety considerations are of high importance Consequences of resource failure: No automatic detection or warning of fire No Public Address system No Warden Intercommunication Phones Contingency strategy options: Increase vigilance – increase frequency of security rounds by orderly Contact repairers and suppliers Inform Fire Brigade How long can operations continue in contingency mode: Indefinitely Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Loss of fire detection and warning systems Responsibility for implementing this strategy: Operations Manager Business Manager Maintenance Manager Criteria for returning to normal operating mode: Rectification of Fire detection and warning systems- back to normal Can this strategy be tested if so how: Yes – disconnect. Locations/Providers: Fire Brigade 000 Wormald Fire Karratha: 9143 1431
Page 40 of 72
This information is available in alternative formats upon request
7.12.1 Fire System Failure
Problem Impact Contingency Action/Tasks Start date End date Responsibility Fire System failure detection system failure Warning system failure
Minimal impact on day-to-day functioning
Increase orderly’s security rounds
Contact suppliers and repairers
Loss of fire system
Restoration of fire system
Maintenace Manager
Inform Fire Brigade
Loss of fire system
Restoration of fire system
Maintenance Manager
Notify all staff of alarm failure and order activiation of contigency plan
Loss of fire system
Restoration of fire system
Maintenance Manager
Fire occurs while alarms not working
Refer to fire and evacuation procedures / task cards
Area warden to order evacuation and contact fire brigade
Loss of fire system
Restoration of fire system
Maintenance Manager
Fire warden to organise communication to remainder of complex
Loss of fire system
Restoration of fire system
Maintenance Manager
Page 41 of 72
This information is available in alternative formats upon request
7.13 Building Management System Failure Description: Failure of Building Management system Impact Rating: Medium Consequences of resource failure: Discomfort of clients and staff due to inability to adjust Air con Auto alarms for failure of A/c will not work Doors: still operable with proximity cards and sensors but no monitoring of door alarms and
faults No CCTV Contingency strategy options: Increase vigilance – increase frequency of security rounds by orderly Contact repairers and suppliers How long can operations continue in contingency mode: Indefinitely Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Loss of building management systems Responsibility for implementing this strategy: Operations Manager Business Manager Maintenance Manager Criteria for returning to normal operating mode: Rectification of building management systems- back to normal Can this strategy be tested if so how: Yes – disconnect. Locations/Providers: Schneider Electrical Perth, John Evans: 6241 0400 Mobile: 0438 886 283
Page 42 of 72
This information is available in alternative formats upon request
7.13.1 Building Management System Failure
Problem Impact Contingency Action/Tasks Start date End date Responsibility Building Management System Failure
Discomfort of clients and staff due to inability to adjust Air con
Connect ROAMIO
Disconnect automated system; adjust manually
Send Maintenance staff to adjust manually
Building management system failure
Building management system restoration
Maintenance Manager
Auto alarms for failure of A/c will not work
Increase monitoring of A/c systems
Send Maintenance staff
Building management system failure
Building management system restoration
Maintenance manager
Doors: still operable with proximity cards and sensors but no monitoring of door alarms and faults
Increase monitoring of doors
Send Maintenance staff
Building management system failure
Building management system restoration
Maintenance manager
No CCTV Increase monitoring
Send Maintenance staff and orderly
Building management system failure
Building management system restoration
Maintenance manager
Page 43 of 72
This information is available in alternative formats upon request
7.14 Loss of Supply Description: Loss of external suppliers Disaster in internal supply Impact Rating: Extreme Consequences of resource failure: Inability to restock low resources leading to inability to provide adequate resources for health
care delivery Contingency strategy options: Increase stock levels held on site Source alternative suppliers Reduce low care, low priority patient load Reduce or cancel operating theatre list and clinics Fly in emergency supplies from Perth Emergency Contact Officer Officer WACHS How long can operations continue in contingency mode: 2 weeks Trigger event/date to invoke the BUSINESS CONTINUITY PLAN: Loss of supply Responsibility for implementing this strategy: District Manager Business Manager Maintenance Manager Support Services Manager Supply Officer Director of Nursing Regional Pharmacist Criteria for returning to normal operating mode: Return of supply Can this strategy be tested if so how: Yes – don’t restock for 2 weeks.
Page 44 of 72
This information is available in alternative formats upon request
Locations/Providers: Regional Supply Manager: 9194 2804 Mobile 0409 818 369 Broome Health Services: 9194 2222 Local food suppliers – Woolworths Derby 9191 1055
Rusty’s IGA 9191 1210 Sampey Meats 9193 2444 Kimberley Distributors Broome 9192 2201
Cleaning chemical suppliers: Progressive Supplies Derby: 1300 853 995 WACHS Emergency Supply contact officer Derby SES Manager: 0418 900 112 or 9191 1501
Page 45 of 72
This information is available in alternative formats upon request
7.14.1 Loss of Supply
Problem Impact Contingency Action/Tasks Start date End date Responsibility Loss of supply (external suppliers fairlure or internal disaster in Supply store)
Inability to restock low resources leading to inability to provide adequate resources for health care delivery
Use Local suppliers:
Make arrangement with local suppliers
Ascertain range of supplies carried by local suppliers
Source local suppliers for all required stores
Annual and ongoing
Return of supply Operations Manager
Business Manager
Maintenance Manager
Support Services Manager
Supply Officer Director of
Nursing
Reduce low care, low priority patient load
Discharge where possible
Make arrangement with Community Care services
Alert community care services
Transfer to community care services
Annual and ongoing
Return of supply Senior Medical Officer
Director of Nursing
Operations Manager
Reduce or cancel operating theatre list and clinics
Reschedule elective surgeries and clinics
Transfer urgent surgeries to Derby
Notify visiting specialists
Loss of supply Return of supply Senior Medical Officer
Director of Nursing
Operations Manager
Continued…
Page 46 of 72
This information is available in alternative formats upon request
Problem Impact Contingency Action/Tasks Start date End date Responsibility Fly in emergency
supplies from Perth Emergency Contact Officer Officer WACHS
Arrange source and delivery of emergency supplies
Notify SES if appropriate
Loss of supply Return of supply Operations Manager
Business Manager
Maintenance Manager
Support Services Manager
Supply Officer Director of
Nursing
Loss of pharmacy supply
Use local suppliers
Source local suppliers
Make arrangements with local suppliers
Annual and ongoing
Return of supply Regional Pharmacist
Continued resource loss beyond 2 weeks
Reduce patient load
Transfer to alternative care suppliers
2weeks after loss of supply
Return of supply Senior Medical Officer
Director of Nursing
Operations Manager
Make arrangements with alternative care suppliers
Annual and ongoing
Senior Medical Officer
Director of Nursing
Operations Manager
Page 47 of 72
This information is available in alternative formats upon request
8. DERBY HEALTH SERVICE – ACUTE INPATIENT SERVICES 8.1 General Ward The standard operating procedures for hospital wide resource failure, e.g. medical gases, air-conditioning and lighting, are to be used in conjunction with the following contingency plans. Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general
Unable to perform duties
Contact Engineering Contact Operations Manager
Await advice from Engineering
Maintenance Manager
BME equipment failure Please be aware Engineering can ONLY carry out MINOR repairs and diagnose faults only
Total Failure Litigation
Engineering will advise of condition and arrange repairs by BME
Arrange transfer from other
sources
Check failed machinery Maintenance Manager
Difficulties in patient observation and care
Contact Nurse Manager and Senior Medical Officer
Prioritise patient care Nurse Manager
Oxygen Wall Supply and Suction Failure
Refer to Section 9.1 General Services
All staff
Pan room hopper – sluice not available
Unable to clean bed pans / urinals adequately
Contact Engineering Maximum numbers of pans
available Use Alternative pan hopper
Engineering and Infection Control to diagnose alternative cleansing methods
Educate staff
Infection Control Nurse
Maintenance Manager
Restrict use of bed pans to “bed rest” clients only
Empty used pans / urinals into toilet
Use disposable bedpans if available
Nursing Staff
Continued…
Page 48 of 72
This information is available in alternative formats upon request
Problem Impact Contingency Action/Tasks Start date End date Responsibility Refrigeration Drugs and
medical supplies requiring refrigeration may become unusable
Contact Engineering Ensure fridges are connected
to essential power supply outlets
Identify fridges on essential power supply
Nurse Manager
Contact Engineering to check calibration of thermometers etc.
Thermometers in fridge to monitor temperature
Nursing staff
Inform staff Nurse Manager
Remove all unnecessary items from fridge.
Transfer to alternate fridge if necessary
Nursing Staff
Staffing Increased manual tasks may influence workload
Roster extra staff on duty Estimate staffing numbers required for 24hrs period
Director of Nursing/Nurse Manager
Place staff “on-call” Prepare rosters Nurse Manager
Liaise with agencies for extra staff where required including post event
Director of Nursing
Page 49 of 72
This information is available in alternative formats upon request
8.2 Obstetrics / Maternity Ward The standard operating procedures for hospital wide resource failure, e.g. medical gases, air-conditioning and lighting, and for the general wards, are to be used in conjunction with the following contingency plans. Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment
Unable to perform duties
Contact Engineering Await advice from Engineering Repairs or alternative feeds to be
determined
Nurse Manager Maintenance
Manager
Infant resuscitation trolleys do not work
Warming and oxygen not immediately available
Use portable oxygen cylinders and warm blankets
Contact Engineering Adequate supply oxygen cylinders Adequate twinovac suction and
attachments
Nurse Manager Support Services
Manager
Ensure cylinders full Support Services Manager
Fill blanket warmer Nursing Staff Dry babies well and wrap and
dress warmly Nursing Staff
Notify Staff Nurse Manager
Oxygen Wall Supply and Suction failure
Refer to Section 9.1 General Services
All staff
Refrigeration of formula and expressed breat milk (EBM)
EBM and formula may become contaminated
Formula made and used as required
Contact Engineering Ensure Refrigerator connected to
essential power supply
Nurse manager
Use fresh EBM or factory prepared formulas
Educate staff Staff development nurse
Thaw frozen EBM and use as per guidelines
Adequate stocks bottled sterile water and formula (powder and prepared)
Nursing staff
Repack frozen EBM into eskies with ice bricks and tiny tag
Discard any defrosted EBM past use by date
Nursing staff
Discard out of date formula / EBM Nursing staff Consent from mothers of use of
formulas Nursing staff
Continued…
Page 50 of 72
This information is available in alternative formats upon request
Problem Impact Contingency Action/Tasks Start date End date Responsibility Labour ward beds cannot be worked
Positioning for labour more difficult
Do without Organise suitable alternative beds and arrange storage
Nurse Manager
Inform staff Cariotocograph (CTG) does not work
Unable to continuously monitor foetal heart
Use battery-powered ultrsound doppler
Adequate supply battery operated dopplers and pinnard stethoscopes
Nurse Manager
Use pinnard Educate staff Staff Development Nurse
Increase intermittent auscultation
Identification of vulnerable patients Nursing staff
Check and repair failed machinery Maintenance Manager
Arrange replacement from BME Nurse Manager Monitors Failure including cardiac and oximetry
Unable to identify arrhythmias / oxygen saturation
Increased nursing & medical observation with manual machinery
Identify and position compliant monitors
Nursing staff
Intravenous Medication (as required)
Identify and ensure adequate medical and nursing staff coverage
Nurse Manager
Cardiac massage (as required)
Identification and Prioritisation of vulnerable patients for monitoring
Nursing Staff
Check and repair failed machinery Maintenance Manager
Ensure enough manual equipment Nurse Manager
Page 51 of 72
This information is available in alternative formats upon request
8.3 Special Care Nursery
The standard operating procedures for hospital wide resource failure, e.g. medical gases, air-conditioning and lighting, and for the general wards, are to be used in conjunction with the following contingency plans.
Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment
Unable to perform duties
Contact Engineering Await advice from Engineering Repairs or alternative feeds to be
determined
Nurse Manager
Humidcrib Failure Difficulty in regulating neonate’s environment
Contact Engineering Use warm blankets Use infant warmer
Develop unit policy Nurse manager
Dress the infant in warm clothes including bonnet and wrap well using warm blankets
Identify supply of warm blankets Nursing staff
Increase observations to 1/24 temperatures
Educate staff Staff Dev. Nurse
Check and repair failed machinery Maintenance Manager Monitors Failure including cardiac and oximetry
Unable to identify arrhythmias / oxygen saturation
Increased nursing and medical observation using stethoscopes
Use apnoea monitor
Idenify and position compliant monitors Nurse Manager
Intravenous medication (as required)
Identify and ensure adequate medical and nursing staff coverage
Nurse Manager
Cardiac massage (as required) Prioritise patients for monitoring and if necessary transfer
Nursing Staff
Replace monitor with other equipment from General Ward/RFDS/Broome Hospital
Investigate close observation of vulnerable patients
Nursing staff
Contact engineering Check and repair failed machinery Maintenance Manager Organise loan equipment from
BME/Broome Hospital Nurse Manager
Suction and Oxygen failure Refer to Section 9.1 General Services
All staff
Phototherapy Equipment Failure
Unable to treat jaundice in infants
Nurse in sunny room but not direct sunlight
Borrow equipment from Broome Transfer to another facility
Nursing staff
Intravenous Pump failure Unable to hydrate neonate safely
Replace with other equipment MO review for change to NGT or transfer to another facility
Nurse Manager
Page 52 of 72
This information is available in alternative formats upon request
8.4 Emergency Department The standard operating procedures for hospital wide resource failure, e.g. medical gases, air-conditioning and lighting, and for the general wards, are to be used in conjunction with the following contingency plans. Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment
Unable to perform duties
Await back up generator to start
Contact Engineering
Await advice from Engineering Identify essential power supply
sockets Utilise manually operated
equipment
Nurse Manager
Monitor Failure including cardiac and oximetry
Unable to identify arrhythmia / oxygen saturation
Increased nursing & medical observation
Identify and position compliant monitors
Nurse manager and staff
Utilise battery powered defibrillators/ BP machines/O2 Sats Monitor
Identify and ensure adequate medical and nursing staff coverage
Nurse Manager
Prioritise patients for monitoring Nursing staff
Increase observations of vulnerable patients
Nursing staff
Defibrillator does not function Unable to defibrillate patients
Increased nursing & medical observation
Identify and position compliant defibrillator
Nurse Manager
Utilise battery back-up defibrillator
Inform and Educate staff Staff Development Nurse
Ensure batteries are charged on a regular basis
Nurse Manager
Communication Failure Refer to PABX section All staff
Ambulance Breakdown Unable to respond to ambulance calls
Source and use alternate vehicles
Contact ambulance suppliers Notify Operations Manager
Nurse Manager Support Service
Manager
Page 53 of 72
This information is available in alternative formats upon request
8.5 Operating Theatre / CSSD The standard operating procedures for hospital wide resource failure, e.g. medical gases, air-conditioning and lighting, and for the general wards, are to be used in conjunction with the following contingency plans. Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment
Unable to perform duties
Conact Engineering Await advice from Engineering
Theatre Coordinator
Anaesthetic machines and ventilators failure
Inaccurate delivery of anaesthetic gases
Hand ventilate Contact Engineering: Application specialist GE Health Care (contact advice on anaesthetic machine)
Theatre Coordinator
Unable to ventilate patients
Use backup cylinder suppiers of O2, nitrous and air
Ensure adequate supply of hand operated ventilation equipment – balck bag, bag – valve device and appropriate cylinders
Theatre Coordinator Support Services
Manager
Utilise oxylogs from Emergency Department (1x Adult 3000; 1x Paeds 2000; 1x Babylog 1000 neonates)
Ensure supplies of cylinder gases Support Services
Manager
Provide air / O2 driven ventilator (oxylog/ birds)
Nurse Manager
Educate staff Staff Development Nurse
Contact Engineering Nurse Manager Monitor Failure including cardiac and oximetry
Unable to identify arrhythmia / oxygen saturation
Increased nursing and medical observation
Theatre Coordinator and Anaesthetist
Utilise portable O2 sats monitor from Theatre (PAC monitor). Other units available in ward or ED
Identify and ensure adequate medical and nursing staff coverage
Nurse Manager
Refer to Emergency department contingency plan
Prioritise patients for monitoring Nursing staff
Increase observation of vulnerable patients
Nursing staff
Page 54 of 72
This information is available in alternative formats upon request
8.6 Community Health The standard operating procedures for hospital wide resource failure, e.g. medical gases, air-conditioning and lighting, and for the general wards, are to be used in conjunction with the following contingency plans. Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment
Unable to perform duties although some limited clinical work may be able to be performed
Contact Engineering Delay any non-essential
clinical work If hospital is not affected refer
essential clinical work to hospital or arrange clinical space to do clinical work.
Await advice from Engineering If unable to transfer clinical work to
the hospital notify management and prioritise workload
Inform public of issues – if all communications down place notice on town notice boards
Contact hospital maintenance by driving to the hospital if safe to do so
Inform IT so information can be sent out to inform KPHU management and stakeholders of communication and service issues
Discuss essential patient care with DON and SMO at hospital to link in with their contingencies
Maintenance Manager
Community Health Manager
Vaccine cold chain breakdown
See contingency for failure of vaccine refrigerator
See action/ tasks for failure of vaccine refrigerator
Community Health Manager
Oxygen Supply Home oxygen users may run out of supply and be unable to resupply
Pre-order extra supplies Hospitalisation
Liaise with HACC to identify vulnerable patients
Community Health Manager
Assess amount of oxygen required and ensure extra supply available
Support Services Manager
Develop alternative treatment plans including hospitalisation if supply runs out and condition deteriorates
Community Health Manager
Continued…
Page 55 of 72
This information is available in alternative formats upon request
Problem Impact Contingency Action/Tasks Responsibility Reduced ability to
respond effectively to accident, walk in or other emergency situation
Always keep a spare cylinder for each size cylinder in use
Contact hospital for back up if supply urgently required
Organise replacement as soon a cylinder is empty
Check equipment regularly Refer to hospital
Support Services Manager
Community Health Vaccine Refrigerators
Break in Cold Chain spoils vaccines
Move vaccines to hospital pharmacy using eskie and ice bricks and tiny tags to maintain cold chain
Advise KPHU Infectious Disease Nurse
Advise Engineer
Community Health Manager
Vaccines can be kept in esky with temp monitor for vaccine clinic and returned to hospital refrigerator at the end of clinic
Inform Regional Immunisation Coordinator (RIC) at Kimberley Population Health Unit (KPHU) and determine the future use or discarding of vaccines (complete wastage report and send to RIC if vaccines discarded)
Community Health Manager
Record all vaccines being discarded vaccines to Regional Pharmacy
Community health staff
Send all discarded vaccines to Regional Pharmacy
Community health staff
Down load the tiny tag monitor from the Community Health refrigerator
Community health staff
Continued…
Page 56 of 72
This information is available in alternative formats upon request
Problem Impact Contingency Action/Tasks Responsibility Computer – HACRe Failure Unable to double
check vaccination status of clients for immunisation
Maintain card system for vaccinations given by Derby Community Health staff
Identify any site with KHR Community Health HACRe
Community Health Manager
Check parents record Contact AICR with client medicare number
Community health staff
Check vaccination history by phone with AICR (Australian Childhood Immunisation Register)
Located in vaccination book Community health staff
If failure is only local phone
RIC to access record on HCARe
If failure regional consider cancelling clinics
Contact IT for instruction on when services can be restored
Contact RIC to organise to contact as required
Inform public if clinic is to be cancelled
Community health manager
Page 57 of 72
This information is available in alternative formats upon request
9. HEALTH SERVICE CRITICAL SERVICES - SUPPORT 9.1 General Services The following standard operating procedures have been generated for application across a number of general services where generic equipment is in place and are grouped thus to avoid replication for tasks for contigency planning for individual services Problem Impact Contingency Action/Tasks Responsibility Oxygen Wall Supply failure Wall oxygen not
available Refer to Medical Gases Section
Wall suction not available
Use cylinder with Twin-o-vac attachment
Contact Engineering Engineering to diagnose and
rectify fault Adequate supply of full air/oxygen
cylinder available
Maintenance manager
Adequate supply of twin-o-vac attachments available
Support services manager
Nurse Manager Identify where equipment is to be
placed (No. requirement) Nurse Manager Nursing staff
Lighting Failure Low light levels may result in OSH issues
Use backup generator Check generator in working order with suuficent fuel in storage
Maintenance Manager
Use areas near to windows Use torches
Clean and maintain windows and fittings
Support Services Manager
Difficulty in client observation and care
Redepoly / evacuate – clients. Refer to hospital internal disaster plan for evacuation proceedures
Adequate supply of torches / battery operated lights and batteries
Maintenance Manager
Check emergency lighting Maintenance Manager
Clear areas and corridors of hazards
Departmental Managers
Educate staff in evacuation plan & OSH
Staff Development Nurse
Continued…
Page 58 of 72
This information is available in alternative formats upon request
Problem Impact Contingency Action/Tasks Responsibility Refrigeration Drugs and medical
supplies requiring refrigeration may become unusable
Ensure fridges are connected to essential power supply outlets
Contact Engineering Maintenance Manager
Ward Managers
Thermometers in fridges to monitor temperature
Ward Manager
Remove all items from fridge Ward Manager Infrom staff Ward Manager Staffing Increased manual
tasks may influence workload
Roster extra staff on duty Estimate staffing numbers required for 24hr period
All Managers
Place staff “on-call” Prepare rosters All Managers Liaise with agencies for extra staff
where required including post event
All Managers
Page 59 of 72
This information is available in alternative formats upon request
9.2 Central Sterilisation (Refer also to Section 7.9- Steam Failure) Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment
Unable to perform duties
Contact Engineering Await advice from Engineering
Theatre Coordinator Maintenance
Manager
Steriliser Pre Vacuums fail Unable to process ward and theatre instruments
Alternative sterilisation methods
Contact Engineering Obtain supplies from Broome
Hospital Transport equipment to Broome
for sterilisation
Engineering CSSD Technician /
Infection Control Nurse
Repair failed equipment Manager Engineering / Maintenance/ Atherton Technician
Instrument Dishwasher fails Unable to clean / sterilise instruments
Clean and wash instruments by hand
Manual cleaning of instruments CSSD Technician
Use ultrasonic to clean instruments
CSSD Technician
Ensure adequate supplies CSSD Technician
Educate staff CSSD Technician
Heat Sealer fails Unable to seal instruments pouches
Use alternative sealing methods
Wrap instruments for sterilisation CSSD Technician
hand dry instruments CSSD Technician
Hot air dryer fails Unable to dry instruments
Dry instruments manually Utilise other methods of heat drying eg air compressor
CSSD Technician
Page 60 of 72
This information is available in alternative formats upon request
9.3 Medical Records NOTE: The standard operating procedures for the general services are to be used in conjunction with the specific procedures detailed below. Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office equipment
Unable to perform duties Contact Engineering Await advice from Engineering Use manual procedures
Maintenance Manager
Failure of HCare Cannot allocate new MRNs
Manual allocation of MRNs Update manual PMI Medical Records Clerk/Receptionist
Cannot search for existing MRNs
Use folder of printable PMI (Patient Master Index) to look up existing MRNs
Print out PMI quarterly Medical Records Clerk
Contact IT in Perth Manually allocate and look up mRNs
Medical Records Clerk/Receptionist
Update system Medical Records
Clerk/Receptionist
Failure of Admission, Transfer, Separation (ATS)
Cannot search ATS to track patients
Not critical, wait until system returns
Update system Medical Records Clerk
Cannot run enquiry reports
Admission lists available in the ED
Maintain Lists of admissions and discharges
ED Receptionist/ Ward Clerks
Page 61 of 72
This information is available in alternative formats upon request
9.4 Pathology Services Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment
Unable to preform duties Contact Engineering Await advice from Engineering Repair or alternative feeds to be
determined
Maintenance Manager
Power Supply Failure Laboratory unable to function without emergency power
Use essential power outlets serviced by emergency generator
Confirm availablity of emergency power
Scientist In Charge
Hand Washing Use bottled water Use Hand sanitiser
Determine suitable hand washing solution
Scientist In Charge
Use prepacked hand washing solution
Adequate supplies hand cleaning solutions
Scientist In Charge
Temperature monitoring software fails.
Unable to determine accurate temperature of Blood Stock fridge & Reagent Fridge
Manual monitoring of fridge temperature using portable probe
Install portable probe Scientist In Charge
Frequent temperature checks Scientist In Charge Alarm monitor failure – Blood Bank Fridge
Rising temperature in fridge may not be recognised. May result in loss of blood supplies, as blood products must be kept at predetermined temperature levels
Monitor fridge temperature manually by portable probe monitor
Pack blood as per blood transport protocols which gives 24hr stability
Install portable probe Scientist In Charge
Transfer blood stores to immunisation fridge
Frequent temperature checks Scientist In Charge
Investigate alternative storage solutions
Scientist In Charge
IT Failure Unable to obtain results Phone 13 7284 for results Photocopy machine printouts
for A+E patients
Nursing and Medical staff
Page 62 of 72
This information is available in alternative formats upon request
9.5 Radiology Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment
Unable to perform duties Contact Maitenance Contact IT and BME
Await advice from Engineering
Maintenance Manager
Failure of radiological imaging equipment
Unable to perform radiological imaging
Have mobile imaging eqipment available for use
Use mobile imagers Medical Imaging Technologist
Cancel / reschedule non urgent exanminations
Medical Imaging Technologist
Repair failed equipment Engineering Power Failure Main equipment not able
to be used. Situation for failure of equipment
Use essential power outlets for mobile equipment
Identify suitable essential power outlets for use
Engineering
Page 63 of 72
This information is available in alternative formats upon request
9.6 Purchasing
Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and general operational equipment
Unable to perform duties Contact Engineering Contact IT
Await advice from Engineering
Maintenance Manager
Engineering Information
Technology Supply computer system failure
Unable to generate orders. Unable to access re-order codes and contracts
Revert to manual system. Use manual order book
Adequate supplies manual order books
Manager Stores
Develop a system to allow access to re-order codes and contracts as at time of loss of service
Manager Stores
Inform Staff Manager Stores Retropective data entry system
when system “online” Manager Stores
Unable to access supplier contact details (phone, fax address details)
Refer to Supplier Catalogues Update suppier Catalogues Manager Stores
Print out a report of all supplier names, addresses and contact details as a manual reference
Manager Stores
Connect essential equipment to emergency power outlets
Determine number essential power outlets in the department
Manager Stores
Unable to verify reciept of goods for accounting purposes
Unable to pay suppliers Manual checking of goods and/or verifying with appropiate department
Develop system for manual checking receipt of goods
Manager Stores
Educate staff Manager Stores Unable to extract item and
customer usage reports No feasible contingency
Unable to determine outstanding orders
Refer to full purchasing listing Update purchase listing report Manager Stores
Refer to store copies of orders
Print out a full purchase listing report as a manual reference
Manager Stores
Unable to recharge fork lift Recharge through essential power supply
Locate suitable essential power supply outlet
Manager Stores
Page 64 of 72
This information is available in alternative formats upon request
9.7 Linen Services Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipment
Unable to perform duties Contact Engineering Await advice from Engineering
Maintenance Manager
Failure of washing machines (2 machines)
Reduced linen service Alter work practices so that other service is maintained
Contact engineering for remedial works
Lengthen washing times
Support Services Manager
Loss of 3 machines Laundry hours extended to accommodate extra work
Implement contingency staff roster for this situation
Support Services Manager
Loss of all machines No laundry service Send linen to alternative services – will be external e.g. Broome Hospital
Source alternative linen services e.g. Detention Centre
Support Services Manager
Arrange transport of soiled and clean linen
Support Services Manager
Arrange realocation of staff Support Services Manager
Failure of drying machines Reduced drying services Contact engineering for remedial works
Identify area for drying linen Contact Boab Inn to utilise facilities
Support Services Manager
Chemical Dispenser Failure Linen not washed to correct standard
Contact Maintenance Send linen to Broome for
laundering
Await advice from Maintenance Contact Broome Hospital Support
Service Manager
Maintenance Manager
Support Services Manager
Page 65 of 72
This information is available in alternative formats upon request
9.8 Catering Services Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipement
Unable to perform duties Contact engineering Await advice from engineering Repairs or alternative feeds to be
determined
Maintenance Manager
Ovens fail, no hot food Supply hot food from alternative premesis
Identify other premises for use in preparing hot food e.g. NNNH
Commercial kitchen contractors Hotels etc
Support Services Manager
Business Manager
Supply cold food Determine supply levels of cold food required
Support Services Manager
Determine sources to replenish stocks of cold food if system is inactive for a long period
Support Services Manager
Business Manager Refrigeration / cool rooms fail Food spoilage Cool rooms connected to
emergency generator Check generator every 4 hours Maintenance
Manager Emergency generator
failure Source food off campus Assess availability of emergency
power through Horizon Power Maintenance
Manager Source alternative facilities Support Services
Manager Develop plan for preparation and
transport of food and relocation of staff
Support Services Manager
Implement plan Support Services Manager
Dishwashers fail Unable to clean dishes Wash equipment by hand Adequate supply of gloves, equipment Support Services Manager
Increase staffing if equipment fails for more than 24 hours
Support Services Manager
Stores/Supplies not delivered No food Contact Lead suppliers Purchase locally Support Services Manager
Page 66 of 72
This information is available in alternative formats upon request
9.9 Mortuary Problem Impact Contingency Action/Tasks Responsibility ALL EQUIPMENT FAILURE Including office and medical equipment and general operational equipement
Unable to perform duties Contact Engineering Await advice from engineering
Maintenance Manager
Loss of refrigeration Unable to preserve the deceased
Transport deceased to alternative
Transport to Broome Health Service
Support Services Manager
In event of essential power failure use portable generator
Monitor every 2 hours Maintenance Manager
Use alternative refrigeration (e.g. refrigerated trucks)
Source alternative facilities Support Services Manager
Business Manager Develop plan for preparation and
transport of deceased and relocation of staff
Business Manager
Educate Staff Staff Development Nurse
Implement plan Business Manager Inadequate number of trays in cool room due to disaster
OSH standards compromised
Stack cadavers on cool room floor
Ensure deceased are tagged correctly
Transport to alternative mortuaries
Contact Broome Health Service Sorce alternative cold rooms Educate staff
Support Services Manager
Maintenance Manager
Page 67 of 72
Effective:
This information is available in alternative formats upon request
Page 68 of 61
Effective: 1 October 2014
APPENDIX 1: BUSINESS CONTINUITY PLAN – TRAINING AND TESTING PLAN
Title of Training or Test What type and method of training or testing will be used.
Hospital/Department/Unit involved in training or test
Location of Training/Test Length of Training/Test Objective(s) of Training or Test 1. 2. 3. 4. 5. Resources Yes No Critical Resources to be trained or tested People
Information Technology Vital Documents - Hard Copy - Electronic Data
Facilities Internal Dependencies
External Dependencies Exclusions from Training or Test (what will not be in the training or test)
Support Requirements (what equipment, staffing, facilities, scripts will I need)
Completed By: (Name and Position)
Approved By: (Name and Position)
This information is available in alternative formats upon request
BUSINESS CONTINUITY PLAN – TRAINING AND TESTING REPORT
Date/Time Record of events and actions taken By Whom? Date/Time Record of events and actions taken By Whom? TIME EXERCISE STOOD DOWN @____________HRS DEBRIEF/COMMENTS/EVALUATION: RECOMMENDATIONS:
Page 69 of 72
This information is available in alternative formats upon request
OUTCOMES: PRINT NAME Signature of person completing report: Date Tier 4 Review and Sign off: Date
Copy to Emergency and Disaster Management Committee
Page 70 of 72
This information is available in alternative formats upon request
Appendix 2: SERVICES ON ESSENTIAL POWER 1) Lights and power – powered by emergency generator All Ward offices and patient areas have 50% power points on generator supply. The Cleaner’s store, three general offices and the Birth Suite bathroom do not have generator supply. 50% of all lighting is on Generator supply. All emergency lighting and exit lighting is battery powered and will last for two hours in event of generator failure.
Equipment with battery back-up are:
the Infusion pumps the Dynamaps PCAs Defibrillator Pulse Oximeters.
Page 71 of 72
This information is available in alternative formats upon request
Appendix 3: MEDICAL GASES ESSENTIAL SUPPLY Oxygen:
i) 10 x G in Medical Gas Store
ii) 5 x E in Medical Gas Store
iii) 9 x D in Medical Gas Store
iv) 34 x C in Medical Gas Store
v) 2 x C in Theatre Store
vi) 3 x C in Accident and Emergency Store
vii) 8 x C in General Ward Store.
Nitrous oxide:
i) 2 X C in Medical Gas Store
ii) 2 X E in Medical Gas Store
iii) 2 X C in Theatre.
Page 72 of 72