32089778 organisation resilience workbook

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Organisational Resilience Workbook (May 2010) - This document is not intended as a best practice guide, nor should it be seen as a definitive reference tool. Page 1 of 70

Organisational Resilience Workbook

Table of Contents

INTRODUCTION TO BUSINESS CONTINUITY MANAGEMENT (BCM).........................................................1

INTEGRATED BCM PROCESS........................................................................................................................ 2

OVERLAPPING CLUSTERS OF ACTIVITIES AND PLANS ............................................................................ 3

CRITICALITIES AND SUCCESSES.................................................................................................................. 5

RESILIENCE STRATEGIES.............................................................................................................................. 6

SPECIFIC PLANNING STEPS..........................................................................................................................7

RELOCATE OR STAY?....................................................................................................................................8

HOW PREPARED ARE YOU?..........................................................................................................................9

KEY QUESTIONS TO ASK (AND HAVE ANSWERS TO).............................................................................. 11

BUSINESS CONTINUITY PLANNING TEMPLATE........................................................................................ 12

DISCLAIMER

The information provided in thisdocument is intended for general useonly. It is not a definitive guide to thelaw and best practice, does notconstitute formal advice, and does nottake into consideration the particularcircumstances and needs of yourorganisation. Every effort has beenmade to ensure the accuracy andcompleteness of this document at the

date of publication for this generaluse.


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Establishing Understanding

Risk Assessment

Establishing the Context

Risk Identification

Risk Analysis

Risk Evaluation(Business Impact Analysis)

Communicat

ion&Consultation

Monitoring&Review

Developing Capabilities

Risk Treatment

Establishing Strategies

Maintenance Actions &

Resources

IncidentCommunications

Plan Activation & Deployment

PlanDocumentation

Establishing Understanding

Risk Assessment

Establishing the Context

Risk Identification

Risk Analysis

Risk Evaluation(Business Impact Analysis)

Communicat

ion&Consultation

Monitoring&Review

Developing Capabilities

Risk Treatment



Resources



PlanDocumentation



Resources



PlanDocumentation

BCM is focused on the understanding of uncertainty and how organisations could respond to and manage that uncertainty.

BCM provides an analytical framework which assists decision makers in making informed choices on the management of continuity risk and events.

Integrated BCM process

BCM should be integrated with the organisations existing overarching organisational-wide risk management framework and processes.

BCM is a cyclical risk management process as described in ISO 31000:2009 risk

management standard (draft). It is an iterative process whereby the outcomes ofeach stage are used to challenge and review the assumptions and outcomes ofprevious stages, through the monitoring and review process.

The process for BCM is represented in the diagram on the right2.

BCM goes well beyond implementing a simple process and writing businesscontinuity plans and strategies. Strategies and plans need to be flexible and adaptive,and decision makers need to appreciate the uncertainty and complexity of an event(e.g. transfer/ relocation to an alternate facility/ location).

BCM should reflect the organisations unique culture and comprise a comprehensiveset of activities that are appropriately integrated into organisational learning andimprovement.

2Draft AS/ NZS5050:2009 BCM standard


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Resumption

Response

RecoveryRestoration

Risk Mgt -Prevention/Mitigation

Control &Command

(Risk MgtPolicy &

Plan)

(Response &

ContingencyPlans)

(Recovery

Plans)

(Governance

Structure &Crisis/ Media

Mgt Plan)

(RestorationPlans)

(Resumption

Plans)

Overlapping clusters of activities and plans

There are six (6) overlapping, non-linear, clusters of activities that organisations have to consider doing before, during and after a disruption or anemergency. These activities depend on the circumstances, impact, and organisational context and maturity. They overlap because one or more of theseactivities can be activated concurrently and/or sequentially, in no particular linear order or sequence.

These six overlapping clusters of activities are:

Risk management prevention and risk mitigation.

Response immediate management (in response to an

event/ emergency/ crisis/ disaster).

Recovery to recover interim/ partial services and/or

operations.

Restoration to restore to full service and operations.

Resumption normalisation, back to business as usual

services and/or operations, where possible/ practical.

Control and/or command governance structuresthat

manage these six (6) overlapping clusters of activities.

Corresponding to these activities are strategies and plans thatcollectively bring together the following topics and planning intoeither one single document (for smaller organisations) or severaldocuments (for larger organisations):

Risk management policy and plan an overarching

framework and process to communicate and consult with

stakeholders, establish the context, identify, analyse,evaluate, treat, monitor and review risks.

Crisis/ media management planning steps taken to

maintain reputation and to execute the relevant

communication and media management strategies or

protocols/ plans.


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Response planning- steps taken to immediately respond to the disruption or emergency, ensuring human safety and security, and maintaining

communication.

Contingency planning- steps taken to activate or restore alternate processes, systems and physical locations/ facilities, where appropriate and

necessary.

Recovery planning- steps taken to restore specified critical and/or key infrastructure requirements/ dependencies such as utilities,

communications, supplies and technology.

Restoration planning- steps to provide limited to normal business services and/or operations, like rebuilding a fire damaged building.

Resumption planning- steps to bring service levels, operations and/or facilities back to business-as-usual, or providing back-to-normal services

to customers from minimum service levels.

Due to inter-dependencies with other agencies (federal, state and municipality), an integrated, multi-agency organisational response at local, regionaland national level may also be required, especially during a wide-spread community emergencies like bush fire or floods.

A BCM program involves an integrated organisational-wide process of:

Establishment of the program/ project (with strong Board and management mandate and commitment).

Development of the organisations BCM policy and framework (linked to your organisations risk management framework).

Risk assessment and impact analysis (using criticality and dependency worksheet)

Establishing governance structures for incident command, management, recovery and support.

Development of cost-effective intuitive strategies and plans that are aligned to organisational objectives.

Development and testing of strategies and plans

Reviewing, maintenance, training and auditing of strategies and plans.


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Criticalities and successes

A committed Board or Management should be satisfied that sufficient infrastructure, budgetary and other resources are allocated and maintained inorder for your organisation to be able to: (i) fulfil the long-term objectives of a BCM program; and (ii) continuously develop, maintain and implementrelevant strategies and plans throughout the life of your organisation. The BCM program is therefore a continuous journey, rather than an end in itself. Itis a long-term commitment by the organisation.

For BCM to be successful, it is necessary to focus on the following performance drivers:

Structured co-ordination- highly structured co-ordination and management arrangements ensure that all planning and systems, from the first

response to recovery (restoration and resumption), are aligned to organisational objectives, and well understood and communicated to all

stakeholders, with roles and responsibilities clearly defined and documented. Workforce capabilities- develop workforce capability and competencies through plans, skills training and adequate provision of technical

equipment and committed resources.

Capacity building- build capacity planning dimensions into services and/or operations, including escalation processes and systems to manage

possible surges in demand for services and service provision.

Inter-operability of plans- ensure inter-operability of planning, co-ordination and operational activities, with diverse arrangements and inter-

connectedness with other component parts of the system and with other external stakeholders like ambulance and police.

Regular exercising and testing of strategies and plans is essential. It ensures that disconnections, omissions and dependencies within strategies andplans are fixed before they are used in reality. Testing challenges assumptions made during the planning process. As such, it is important to:

Test the system and dependencies, and readiness of all stakeholders.

Exercise and review strategies and plans.

Ensure people are rehearsed in how to respond and fully understand their roles and responsibilities.

Regularly update and maintain strategies and plans, especially emergency contact lists.


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Resilience strategies

Critical concepts in business continuity and emergency management are (i) recovery time objective (RTO); and (ii) maximum acceptable outage (MAO).RTO is the period of time required to fully re-establish adequate resource requirements (HB221:2004), whilst MAO is the maximum period of time thatcritical business processes (or services) can operate before the loss of critical resources affects operations (HB221:2004). For example, the RTO for anemergency department is 10 minutes and its MAO is four hours.

Strategies and plans need to have acceptable RTO and MAO that are aligned with the organisations objectives, risk management framework and riskappetite, and in compliance with applicable regulatory and contractual service obligations.

Strategies and plans should also be intuitive and options include, but are not limited to:

Process transfer or relocation involves transfer or relocation of critical and/or time sensitive activities either internally (e.g. to another part or

location of the organisation) or externally (e.g. to a third party location), independently or through a reciprocal/ mutual-aid agreement, or in-principle

agreement.

Agreement to share resourcesthrough mutual aid arrangements (e.g. shared data centre).

Temporary/ manual workarounds as an alternative to transferring or relocating people or processes, it might be feasible to adopt a different way

of working that provides an acceptable result in the short to medium term (e.g. using the stairs rather than lifts).

Change, suspend or terminate services, functions or processes- provided conflicts with the organisations key objectives, statutory compliance

or stakeholder expectation are managed appropriately.

Insurance for financial compensationfor losses, used in combination with other strategies.


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Specific planning steps

The planning steps are show in the diagram below.

Understand YourBusiness & EngageThe Right People

Understand YourBusiness & EngageThe Right People

Identify Risks,Weaknesses,

Vulnerabilities,Expectations

Identify Risks,Weaknesses,Vulnerabilities,

Expectations

Make & ChallengeAssumptions (Ask the

Right Questions!)

Make & ChallengeAssumptions (Ask the

Right Questions!)

Identify IntuitiveStrategies & Plans

Identify IntuitiveStrategies & Plans

Develop & ImplementStrategies & Plans,

Governance Structure

Develop & ImplementStrategies & Plans,

Governance Structure

Communicate YourStrategies & Plans;Staff & Community

Training

Communicate YourStrategies & Plans;Staff & Community

Training

Test, Review &

Improve YourStrategies &Plans

Test, Review &

Improve Your

Strategies &Plans

Identify Critical Services,

Dependencies,Capabilities, Capacities

Identify Critical Services,

Dependencies,Capabilities, Capacities


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Relocate or stay?Key decisions as to whether your organisation evacuates or stay-in-shelter in an emergency are shown in the overall mind map below:

Notes

(1) There is no compulsory evacuation

in Victoria.

(2) Responsibility for recommending

relocation rest with Incident

Controller.

(3) The rights of people to stay and

protect their homes are recognised.

(4) Recommendation 7.1 of the

Interim Bushfire Commission

Report (August 2009) states the

principle that practical steps are

needed to protect the vulnerable.

Families with young children,

older people and disabled people

(sic) are advised to plan for early

relocation.

(5) If you are planning to leave the

property, leave early. Avoid the

wait-and-see approach.

Decision toRelocate

or Shelter-In-Place

Internal FactorsExternal Factors

Nature ofEvent

Location ofFacility

Type ofZone

Time

Flood Zone

Metro

Rural

Fire Zone

Impact

HurricaneZone

Physical Structure

Resident Acuity/

Safety/ Security

Staff/ Workforce

Suppliers/Dependencies

Transportation/Evacuation Route

Destination

Likelihood

Advance Planning/Coordination

Communication


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How prepared are you?

This simple checklist will help you identify just how prepared you are for an emergency?

Has your business ... Yes No Action Plans/ Gaps?

1. Documented business continuity/ emergency management strategies and plans

2. Checked to see whether business is complying with relevant legislation, laws, duty of care, etc.

3. Documented aims and objectives for the organisations business continuity/ emergency management strategies andplans

4. Established a project team/ planning committee

5. Established a control/ governance structure for the organisation, including the appointment of appropriate people tospecific roles and responsibilities

6. Developed a process for ongoing maintenance and review of strategies and plans and updating of information

7. Hosted an ongoing program of awareness, education and training for staff/ volunteers, patient/ residents,contractors and visitors

8. Documented and made readily accessible emergency contact lists of all internal and external stakeholders

9. Held regular scenario testing to train staff/ volunteers and test business continuity/ emergency managementstrategies, plans, dependencies and arrangements.

10. Conducted an annual risk assessment for the business and its operations

11. Given priority to training staff in areas of key risks

12. Included familiarisation with business continuity/ emergency management strategies and plans as part of the staff/volunteers induction/ training process

13. Developed building evacuation plans and held regular practice drills

14. Considered the special needs of people with disabilities, etc, in building evacuation plans

15. Established a system to account for all people on your premises (head count management)

16. Established a system to log/ document events in the case of an emergency incident

17. Spoken to your neighbours or community about continuity and emergency planning

18. Established a process for (i) emergency equipment maintenance; and (ii) documented emergency contact lists/numbers of staff/ volunteers, patient/ residents next-of-kin, suppliers and authorities

19. Mapped comprehensive building floor plans and site maps, identifying dependencies including power, water and gassupplies, local roads, neighbours, communities, etc


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Has your business ... Yes No Action Plans/ Gaps?

20. Established strategies and plans for (i) maintaining and activating emergency contact lists for key stakeholders; (ii)relocation of facilities/ services or stay and shelter-in-place; (iii) patient/ resident transportation/ transfers; (iv)maintaining staff and patient/ resident welfare and support; and (v) media management

Check your results

For a perfect score you should answer Yes to all 20 questions.

If your score is 17 to 20 Congratulations! Your business or organisation is definitely one of the best in the area of emergency/ contingency planning.But dont be complacent - things change every day and so there is always maintenance work required.

If your score is 11 to 16 Your organisation is more prepared than most but if there is an emergency/ crisis that impacts on your business ororganisation, chances are you wont have anticipated all of the potential consequences or be adequately prepared torespond. Put emergency planning on your Board and/or Management agenda.

If your score is 10 or less Your organisation is not well prepared and needs to take immediate action or the consequences could be drastic for yourbusiness, staff/ volunteers and patient/ residents in the event of an emergency, including damage to your reputation.

(Adapted fromMind Your Business: An emergency management planning guide for business in the City of Melbourne)


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Key questions to ask (and have answers to)

(1) Which alternate locations/ facilities have been identified if the stay and shelter-in-place option is notappropriate?

(2) In what order of priority (triage) are people evacuated3from your buildings? Process/ procedure in place to verify that all rooms/buildings have been fully evacuated/ relocated/ cleared?

(3) How will you ensure each patient/ resident is clearly identifiable before, during and after relocation/ transfer to alternate locations/facilities?

(4) What are your process/ procedure for ensuring that your staff/ volunteers are available to care for patient/ residents at all alternatefacilities/ locations?

(5) What are your processes/ procedures for notifying patient/ residents emergency contact person of a decision to relocate/ transfer toanother location/ facility or to stay and shelter-in-place?

(6) How are patient/ resident-specific treatment supplies/ requirements identified for transportation to the alternate location/ facility?

(7) How will you obtain all necessary supplies/ inventories if you: (i) evacuate/ relocate to alternate locations/ facilities, or (ii) decide tostay and shelter-in-place?

(8) What are your process/ procedure for transporting patient/ residents medications/ supplies to alternate locations/ facilities?

(9) What are the three (3) most critical resources or dependencies used in your organisation (under normal business-as-usualoperating conditions), e.g. electricity, pharmacy supplies, linen etc.?

(10) How will you manage your patient/ residents care if medical records/ documentation are destroyed and/or are not available?

3Evacuation is a risk management strategy which may be used as a means of mitigating the effects of an emergency or disaster on a community. It involves the movement of people to a safer location. However, to

be effective it must be correctly planned and executed. The process of evacuation is usually considered to include the return of the affected community. (Emergency Management Australia, Evacuation Planning(Manual Number 11), 2005)


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Business continuity planning template

This is a step-by-step guide for healthcare, health services and community services providers to plan and be prepared for an emergency or a pandemic.Wider research/ consultation may be required to ensure your strategies and plans cover the unique needs/ circumstances of your organisation.

No one knows when an emergency, a crisis or a pandemic outbreak might occur or how severe it might be or what impact it might have on your normaloperations. In this way, planning for an emergency or a pandemic is like planning for an earthquake. The important thing is that you take the appropriatesteps nowto protect your staff, volunteers, patient/ residents and third parties for potential adverse future events.

1. Getting started Tick/ date

Turn this template/ worksheet into action plans to suit your particular circumstances

Wider research/ consultation may be required to ensure your strategies and plans cover the unique needs/ circumstances of yourorganisation, business and operations.

Appoint a manager and deputy/ alternate

This will often be senior management staff. The manager will develop your organisations strategies and plans including outlining the primary roles and responsibilities ofkey participants/ stakeholders within and external to the organisation. Please consult and communicated with key stakeholders - Board, Management, staff/ volunteers,patient/ residents, carers, as necessary. Having a dedicated person who is going to be responsible for business continuity is vital to the long-term success of your BCM

program.

Name: Contact no.: Alt Contact no.:

Alternate name: Contact no.: Alt Contact no.:

Alternate name: Contact no.: Alt Contact no.:


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Basic information about your facility

This may be required for each facility managed by your organisation, if they are located in different geographical locations.

Name of facility, address, telephone number, emergency contact, telephoneand fax numbers, e-mail address

Owner of facility, address, telephone number, e-mail (if applicable)

Year of facility was built

Name of administrator, address, work/ home telephone number, e-mail (ifapplicable)

Number of facility beds

Maximum number of patient/ residents on site

Average number of patient/ residents on site


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Type of patient/ residents served by the facility to include (but not limited to):

(1) Patient/ residents with Alzheimer/ Dementia, etc.

(2) Patient/ residents requiring special equipment or other special care, such asoxygen or dialysis.

(3) Number of patient/ residents who are self-sufficient/ mobile/ independent

(4) Others

Type of geographical zone this site/ facility is located in

(1) Fire zone

(2) Flood zone

(3) Others


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Know your points of contact with your local DH/ DHS/ DOHA representative, essential services (like Victoria Police, State Emergency Services, Fire

Authority, and Ambulance Victoria), media and local council, etc.Leading into an emergency/ a pandemic, you will need to identify who your correct point of contacts are and how to contact them on a 24X7 basis. Form strongpersonal relationships with these external stakeholders.

Department of Health - regional or local office

Name 1:

Name 2:

Contact no.: Alt Contact no.:


Department of Human Services- regional or local office

Name 1:

Name 2:



Victorian office of the Department of Health and Ageing (DOHA)- regional or local office

Name 1:

Name 2:



Victoria Police- regional or local office

Name 1:

Name 2:



Fire Brigade/ Authority (MFB/ CFA)- regional or local office

Name 1:

Name 2:




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Ambulance Victoria/ Ambulance Control- regional or local office

Name 1:

Name 2:



Council regional, shire, municipal or local

Name 1:

Name 2:



State Emergency Service (VICSES)- regional or local office

Name 1:

Name 2:



Media/ ABC Radio/ newspapers- regional or local office

Name 1:

Name 2:



Others (Please specify) ________________________________________

Name 1:

Name 2:




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2. Working with your community of contacts Tick/ date

Consult with and inform relevant stakeholders about your strategies and plans and what they can do to help. Take care not to causealarm.

Topics to cover include:

What your organisation is doing to prepare and plan?

What patient/ residents and families/ carers can do to prepare?

What you need from them so that they can assist in your planning, including what their roles and responsibilities would be?

Next steps.

Consider also how your organisation would communicate with staff/ volunteers, patient/ residents, etc. in later phases (especially recovery,resumption and restoration).

Board Members/ Minister

Name:

Name:

Name:




Build links with the following agencies, community support networks, etc.

Nearest hospitals (private and public)

Hospital 1:

Hospital 2:

Hospital 3:





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Local doctors/ out-of-hours GP services

Doctor 1:

Doctor 2:

Doctor 3:




Local chemist/ pharmacies

Chemist 1:

Chemist 2:

Chemist 3:




Local community hall/ civil centres/ neighbourhood houses

Name 1:

Name 2:

Name 3:




Local/ district nurses

Nurse 1:

Nurse 2:

Nurse 3:





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Local schools/ kindergartens

School/ kindergarten 1:








Build links with the following organisations/ dependencies - this should be linked to your contract management system, whereby a list of key contracts arecentrally maintained and kept updated

Power/ electricity provider

Name 1:

Name 2:



Water provider

Name 1:

Name 2:



Gas/ medical gases provider

Name 1:

Name 2:




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Mobile/ back-up power generator provider

Name 1:

Name 2:



IT/ Communication provider

Name 1:

Name 2:



Waste disposal/ sanitation provider

Name 1:

Name 2:



Tenant(s)

Name 1:

Name 2:



Voluntary/ community groups e.g. Red Cross, Rotary Club

Name 1:

Name 2:




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Financial institution/ bank(s) operations, investments, payroll

Name 1:

Name 2:



Insurers

Name 1:

Name 2:



Temporary staffing/ employment agencies

Name 1:

Name 2:



Food Supplier

Name 1:

Name 2:



Key Supplier: ___________________________________________

Name 1:

Name 2:




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3. Contact lists, roles/ responsibilities and resources Tick/ date

Set up comprehensive emergency contact list(s) and update/ test it regularly

Attach the following emergency contact lists as Appendices to your plans.

Staff (full-time, part-time, etc,) home/ emergency contacts details (preferably having two emergency contacts) indicate if theyare willing to carry out alternative duties (for example, in health or welfare roles).

You may want to have a dedicated 1800 contact number for your staff/ volunteers to use exclusively to ring in and tofind out what is going on and what help they can provide (rather than using or overwhelming the general number)

Volunteers home/ emergency contacts details. Conduct all necessary regulatory pre-checks on volunteers beforeincluding them on your emergency contact list.

Parents/ carers/ next-of-kin contact details - at least two local emergency contact details for each patient/ resident

Key supplier/ stakeholder contact details

What are the business rules to trigger the use of these emergency contact lists?

Process/ procedures to use these emergency contact lists? Pre-approved written messages/ script used?

Process/ procedures to verify that everyone (that requires to be contacted) on these emergency lists has been contacted and understands themessage/ instruction conveyed?

How often are these emergency contact lists updated/ checked/ reviewed? (at least once a year)

How often are these emergency contact lists tested/ checked/ reviewed? (at least once a year)


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Issues to consider Right people having the right information at the right time Notes

4. Establish a planning team

4.1. Gain Board and/or Senior Management support and mandate to: ( i) develop and maintain strategies and plans, and (ii) maintainthe BCM program in the long-term.

Support and mandate for the BCM program and strategies documented/ minuted?

Ensure Board/ SeniorManagement understand thepros and cons of advanceplanning, developing and testingstrategies and plans, andcommitting organisationalresources to the BCM program.

Be prepared and delegate

responsibility to others to helpduring an emergency.

4.2. Existence of command and control structure to provide governance, management and decision-making during an emergency/ apandemic? Process/ procedure to review command, control and coordination arrangements for each site/ location to ensure thatthey are capable of being adapted and/or flexible to the needs of evacuation or shelter-in-place?

Same governance structure used for both the emergency management and business continuity programs?

Who is assigned to communicate with the media/ press and/or issue press releases?

What is the decision-making process during an emergency/ a pandemic?

Process/ procedure to document key decisions made during an emergency/ a pandemic?

Who is responsible for documenting the facts/ sequence of events and/or key decisions made?

Existing governance for yourcommand and control structuresshould be optimally used.Everyone involved should knowtheir exact roles andresponsibilities during anemergency/ a pandemic.

Avoid duplicating governancestructures and roles, wherepossible/ practical.

The CEO is generally assignedto communicate with authorities,media, etc.

All key decisions and factsshould be logged/ documentedand reported appropriately andimmediately. The appropriatecommand, control and

coordination arrangementsshould be established as soon asis practicable after the event.


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4.3.

What emergency and evacuation plans (or similar) are currently in place?

How effective are these plans? Perform a gap analysis to determine potential areas of improvements to close any gaps?

Where these plans are kept (preferably off-site) and how updated/ current are they?

Copies of updated key diagrams and site drawings kept off-site, in secure and safe location?

Build on what the organisationcurrently have and develop/ writeplans only to close any gapsidentified.

A full set of plans should be keptoff-site and assessable by keystaff, when required.

Updated copies of diagrams (e.g.engineering systems) and sitedrawings (e.g. building plans)should be kept off-site, securelyand safely, where possible.

4.4 Are these strategies and plans classified as confidential/ organisational secrets and be made available on a need-to-know basis? Unauthorised access mayexpose your vulnerabilities.Access to plans must berestricted on a need-to-know-basis and controlled as part ofthe organisations informationsecurity policy.

5. Understanding your context Notes

5.1. Are your business continuity/ emergency management aligned: (i) within your organisations overarching risk management policy

and plan; and (ii) to your organisational objectives?

What is the maturity of your organisations risk management framework and process? Where are the gaps?

Business continuity and

emergency managementprogram is developed within abroader organisational riskmanagement framework. Yourrisk management framework isthe foundation for your businesscontinuity and emergencymanagement program.


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5.2.

Explore/ understand the organisations threshold for maintaining business-as-usual, based on the organisations risk appetite(risk averse or risk taker) and operational circumstances.

What is your organisations risk tolerance (based on risk management policy)?

There is no one-size-fit-allsolution to business continuityand emergency management.

5.3. Is your facility part of a larger entity/ group?

Who do you need to talk to for incorporating your strategies and plans into a wider entity-level planning?

Incorporate your planning intothe larger entitys overall plans,ensuring that your organisationhas been considered as part ofthat entitys overall planningprocess.

5.4. Develop a common understanding of the level of threat or risks poses to your organisation/ facilities, especially for decisionmaking and establishing the required/ necessary business rules and triggers.

What are the top five (5) service continuity risksfaced by your organisation/ operational site/ location/ facility?

Risk 1:

Risk 2:

Risk 3:

Risk 4:

Risk 5:

As part of your planning, it isimperative that a risk assessmentstarts the process. Site specificevacuation and shelter plansshould be informed by r isks mostlikely to impact the site and thewider local area using relevantresources. Within the site, thisshould include the risksassociated with the location andcertain types of patient/ residents(of this location) in relation to theease of evacuation/ relocation.


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5.5.

What, where and/or who is your information source (e.g. radio (774 ABC Radio?), internet (Bureau of Meteorology, CFA, etc),newspapers, etc.) - to include off hours and weekends/ holidays, on a 24/7 basis?

Is the information source accurate, timely and/or complete?

If so, can the information be an input to your decision making process?

Do your communication framework/ process include all applicable stakeholders?

Organisations need to monitorthese authorised/ pre-determined/ pre-approvedinformation sources for regularupdates or news.

During the course of anevacuation/ relocation andshelter-in-place event,organisations will need to takeinto account the need to maintaincommunications to support the

process and the need to dealwith stakeholders.

5.6. What planning assumptions are you going to make when you develop your strategies and plans? Verify, test and challenge allplanning assumptions so that your strategies and plans are reasonable, relevant and/or appropriate, given: (i) your uniqueoperational constraints and environment, and (ii) the types of patient/ residents you have for each location/ facility.

Assumption 1:

Assumption 2:

Assumption 3:

Assumption 4:

Assumption 5:

Some possible assumptions-

Rely on local council bussesfor evacuation to alternatelocation.

Rely on XX to take over themanagement of theemergency (help will arrive).

Ambulance Victoria cansupply five ambulanceswhen called upon.

Staff absenteeism mayincrease by xx% (fluseason).

Staff will show up for work,

regardless.

Key suppliers will be therefor us, regardless.


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5.7.

Identify and document triggers and/or business rules that would clearly help you decide whether to:(1) Escalate information upwards (within your organisational and reporting/ communication frameworks)

(2) Activate the necessary plan(s)/ phases/ activities Includes who (title, not name) makes the decision to activate/ trigger theplan? Who will make the decision, if this person is not available?

(3) Discharge non-critical patient/ residents (non-medically independent).

(4) Evacuate/ relocate patient/ residents to other alternate location(s) temperature, relative humidity, wind direction, windspeed, wind change, etc.

(5) Stay and shelter-in-place.

(6) Scale down services (provided the organisation is not an essential service provider).

a. Develop strategies and plans for reducing services to external parties.

b. Develop strategies and plans for notifying patient/ residents of changes to normal services.

.

Use all-hazards, all agencies andcommunity-focused approach.

Reporting/ escalating frameworkshould minimise loss of timely/accurate information flowingwithin the organisation.

Pre-defined and pre-approvedtriggers and/or business rules.This would ensure clarity of rolesand responsibilities, and avoidsconfusion and uncertainty duringan emergency/ a pandemic.

Available lead time may influencethe decision to evacuate/relocate.

Examine the space of a facility tobe used as a shelter-in-place andensure it meets your needs forspace, accommodations,restrooms, and a kitchen. Youhave a duty of care to provide a

safe and secure shelter-in-place.

Managing stakeholdersexpectations are important toensure that your strategies/ planscan be executed and meet allnecessary conditions andrequirements.


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5.8.

Arrangements made with the following stakeholders as part of your planning process:(1) Staff, volunteers?

(2) Patient/ residents/ carers/ families/ next-of-kin?

(3) Government/ authorities/ regulators Local, state, federal?

(4) Community, neighbourhood, NGOs/ NFPs?

(5) Key suppliers?

Clarify obligations/ expectationsduring the planning phase toavoid misunderstanding/confusion.

Do not wait to be told toevacuate. Remember the you-are-on-your-own (YOYO)principle. You are on your ownuntil help arrives. In themeantime, immediately after thepoint of disaster, you must have

the necessary plans to succeed(through careful planning), tomaintain your reputation and dutyof care, and to maintain yourability to continuity operatingbeyond the event. Total relianceon external parties to help yourorganisation to be resilient toemergencies should be avoidedor minimised.

Community-centred approach/

focus - This is the level at whichsome of the most meaningful/effective activities take place.Community participation indecision-making, implementation,and monitoring and evaluation ofplans increases theappropriateness and successesof an early recovery interventionsand response.


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5.9. Site location maps and documents outlining the organisations structure are up-to-date and regularly reviewed? Site/ location maps identifyingthe location/ position of allbuildings/ capital assets.

List and location of alltenants.

Colour-coded line drawings ofthe distribution of key utilities,dependencies, etc.

Distribution of all criticalservices.

Links between services andreporting structure.

Google Maps geographical profile

5.10. Profile of your entire workforce and its impact of increased absenteeism on the delivery of critical services? Would your staff notall come to work for various reasons?

Staff may not come to work ifthey are required to take care oftheir children, especially whenschools may be closed during apandemic. Consider:

Rosters.

Vacancy rates.

Casual staff.

On call capacity.

Annual leave liability.

Scheduled leave.

Rates of unplanned leave.

5.11. Process/ procedure to detail your strategies and plans in patient/ resident contracts? Patient/ residents or responsible partiesunderstand and acknowledge these provisions?

Let the family know that thepatient/ resident may bedisplaced for an undeterminedperiod of time.


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5.12. Patient/ residents profile at each location/ facility? Consider (1) acuity; (2) mobility;(3) mental capacity; (4)dependency high or low care;medical condition (hypertension,arthritis, heart disease, cancer,dementia, cognitive impairment,etc).

5.13. Your obligations to third parties if you provide services to other organisations that is, you s a service provider to otherorganisations/ third parties?

Where are copies of these supply contracts kept?

Continuity/ emergency clauses included into these supply contracts?

Financials/ costing agreed and included into these supply contracts (especially in reference to an emergency/ pandemic)?

For example:

Linen.

Transport.

Home care, respite.

Meals, child care.

Supply contracts should includeprovisions for non-delivery ofservices by your organisation inthe event of an emergency/ apandemic (considered as forcemajeure?)


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5.14 What are the physical vulnerabilities for each site/ location/ facility you are managing?

Site/ location/ facility Physical Vulnerabilities/ Risk Assessment Priorities?

1. (i)

(ii)

(iii)

(iv)

2. (i)

(ii)

(iii)

(iv)

3. (i)

(ii)

(iii)

Overhanging trees, bushessurrounding your facility maybecome fuel during the bush fireseason. Understand all physicalvulnerabilities affecting eachfacility through a riskassessment/ identificationprocess.

This is part of tree/ vegetationmanagement, fuel reduction.Victorian Government

announced the following: Residents will not need a

council permit to clear anyvegetation, including trees,within 10 metres of theirhouse.

Lower-lying vegetation suchas shrubs and ''ground fuel''will be able to be cleared upto 30 metres from their

house. Land owners will be

permitted to clear trees andother vegetation up to fourmetres either side of theirfence lines, provided theyhave the consent of theirneighbour.

People will be allowed tocollect firewood ''as of right''

from roadside areas thathave been identified asposing a high fire-risk areatargeted for planned burningby the CFA.


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5.15 Determine that emergency and disaster management (particularly response) procurement requirements have been identified withrelevant solutions incorporated into:

(1) Procurement policies

(2) Financial delegations

(3) Contractual delegations

(4) Contracts with key suppliers

(5) Contracts with suppliers who could be important / critical to response and recovery plans


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5.16 Implications of a local and regional emergency / disaster been considered and strategies formalised to mitigate the impact?

Strategies to improve community resilience so that the community can plan their response in the event of an emergency?

Relevance of CFAs Community Fireguard?


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5.17 Process/ procedure to review the following documentation:

(1) Municipal Emergency Management Plans

(2) Municipal Fire Prevention Plans

(3) Township Protection Plans (CFA)

(4) Location of high risk bushfire zones

(5) Victorian Fire Risk Register

(6) Neighbourhood Safer Places

(7) Wildfire Management Overlay


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6. Risk identification and analysis

6.1. What is your duty of care (common law or statutory or legal) to provide a healthy and/or safe environment to:

(1) Staff, volunteers (at your own facilities/ locations and at all planned alternate locations/ facilities)?

(2) Patient/ residents/ carers/ families?

(3) Contractors, third parties, visitors, suppliers?

A principle of health and safetyprotection is for employees,other persons at work andmembers of the public be giventhe highest level of protectionagainst risks to their health andsafety that is reasonablypracticable in the circumstances.(Occupational Health and SafetyAct 2004). Employers cannotdelegate accountability/ liability tothird parties.

Part 4.6, Quality of CarePrinciples 1997, under thesection labelled Fire, securityand other emergencies specifiesthe outcomes whereManagement and staff areactively working to provide anenvironment and safe systems of

work that minimise fire, securityand emergency risks.


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6.2. What are your key legal, regulatory and contractual requirements relevant for your operations/ facilit ies?

Do you have a compliance matrix?

Can you meet all of these obligations during an emergency/ a pandemic? Decision not to meet (fully/ partially) legal andregulatory requirements must be endorsed, at least, by the Executive and/or CEO and/or Board?

Having an updated compliancematrix assist in determining keycompliance areas to be followedin an emergency/ a pandemic.

Have open and frank discussionswith staff/ stakeholders on theirobligations. Staff can withholdtheir services for whatever

reason during an emergency(e.g. pandemic, bush fire).

6.3. Anticipated what increased services consumers/ third parties may require from you during an emergency/ a pandemic (e.g. as areceiving facility)?

If requested, collaborate with local agencies in making your facility available in local emergency response efforts. Can you cope

as a receiving facility, where there is a surge of patient/ residents from another facility? Are your inventories sufficient? Ability toprovide a home-away-from-home environment? Have process/ procedures in place to ensure that sufficient lead time iscommunicated to you?

Do you have additional resources available ready to assist? Are cost of service delivery (and chargeable to other organisation)agreed upon with the other organisation if your facility is made available to other third parties?

You may be asked to receiveadditional patient/ residents fromother facilities.

Clarify what cost is appropriatefor making your facility availableas the receiving location.


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6.4. Identify your critical services and/or business processes, rank them in order of importance and determine their maximumacceptable outage (MAO). Would your facility/ site have priority over other businesses in your locality (e.g. restoration of powerdue to power blackout)?

Service/ Process Ranking/ Criticality MAO (Hours)

Use the criticality and

dependency worksheet, wherepossible.

MAO is the maximum period oftime that critical businessprocesses (or services) canoperate before the loss of criticalresources affects operations(HB221:2004).


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6.5. Confirm existing written protocols, business rules and/or procedures for each of these critical activities/ functions.

Identify new ones, where gaps are found (after gap analysis).

Standard operational procedures

for critical services/ functionsshould be developed. These mayinclude:

Criteria for establishingemergency teams.

Information flows (drafting ofsituation reports (SITREPS),briefings, back-up ofinformation, etc.).

Development anddissemination of publicinformation.

Human resourcemanagement during anemergency/ a pandemic.

6.6. Identify essential resources/ dependencies required to meet the demands of critical services and/or business processes. Wherematching criticalities/ dependencies are identified, determine their priorities and develop any action/ project plans required toclose any identified gaps. (Use the worksheet where possible/ practicable)

Dependencies/ resourcesinclude:

Staffing (capacity,capability).

Utilities electricity, water,sewerage, gas, etc.

Waste disposal.

Food, linen, etc.

Systems IT,communication, payroll, etc

Lifts, physical access.

Inventories, supplies.

Air conditioning, heating,etc.

6.7. Validate and document the level of redundancy (excess capacity) for all of the key resources identified, if any. By understanding your level ofexcess capacity, you are able toprovide some buffer in the eventof an emergency/ a pandemic.


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6.8. Understand significant inter-dependencies/ intra-dependencies between

Critical services

Critical business services/ processes

Other essential resources/ dependencies (e.g. IT depends on electricity)

Key personnel/ human resources required

This is to ensure that all

dependencies are managedaccordingly and appropriately.

6.9. Identify single points of failure, where possible, for dependencies listed above. Conduct a walk through test/ review to determinepossible single points of failure, understanding its causes and risks.

A single point of failure is part ofa system which, if it fails, will stopthe entire or substantial part ofthe system from working. Forexample, lifts may not be linkedto emergency back-up powergenerator and therefore, will notoperate during a major powerfailure.

6.10. Assess the appropriateness/ completeness of your preventative maintenance program and/or breakdown maintenanceprocedures in order to manage essential resources/ dependencies.

Determine how long these arrangements could be maintained without ongoing support or maintenance.

All preventive/ contractorsservices must be independentlyverified to ensure that work isactually done in accordance toagreed service contracts. Forexample, smoke alarms regularlyserviced by third parties.

6.11. Identify the key personnel and/or core skills required to maintain critical services and/or business processes. People with the right skills/competencies should beidentified to ensure that criticalservices and/or businessprocesses can adequatelyfunction during emergencies.


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6.12. Review your organisations risk register to understand which risks will impact on the continuity of critical services and/or business

processes.

Your risk register may reflect key

physical vulnerabilities impactingthe organisation.

6.13. Identify potential financial and non-financial exposures and impacts, where possible/ practical. Examples include:

Cash flow availability topurchase additional suppliesor services.

Ability to meet increased staffcosts.

Ability of the switchboard/reception to manage asignificant increase in internaland external calls.

Food and fuel stores.

Theft of key supplies.

6.14. Can service level agreements or contracts executed by the organisation be amended/ adjusted to allow for reduced servicesduring an emergency/ a pandemic?

Discuss contingencies with keystakeholders as required anddocument variations in contracts.Flexibility to vary contractualterms ensures that you are not inbreach of your contractualobligations to third parties.

6.15. Determine what level of staff absenteeism could be tolerated for critical services and/or business processes, before minimum

service is no longer possible.

Review this as part of an

employees conditions ofemployment where staff shouldattempt to come to work in anevent of an emergency/ apandemic, especially in theinterest of the organisation or asa moral obligation to your patient/residents.


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6.16. Verify whether any services and/or business processes could be operated remotely using telephone, fax and e-mail/ internet,

where possible (e.g. administration work/ task). This is linked to your work-at-home policies.

How many users can concurrently log-on remotely into your IT network to perform work from home without crashing the system/servers?

Staff can work from home if they

are unable to come to work forwhatever reason.

By understanding your IT systemlimitations, you are able to pre-grant the necessary remoteaccess to your staff, based onposition and/or operational need.

6.17. Process/ procedure to continue paying staff for protracted absence from work, especially during a widespread emergency/pandemic?

Which bank is handling your payroll payments/ processing?

Is manual and/or remote payroll process possible?

Is your bank aware of your strategies and plans in relation to payroll processing?

Who is authorised to instruct your bank to make the necessary payroll payments in the event of an emergency/ a pandemic?

What documentation is required for such approval (if it differs from business-as-usual processing)?

Pay your staff in whatevercircumstances, especially if youwant them to work in anemergency and especially if itover and above their normal jobrequirements.

Pre-arrangements with your bankis vital to ensure that yourworkforce gets payed on time,regardless. Remote payroll

processing capability may benecessary. This may also requireaccess to your finance staff andfunding/ cash flow to make thenecessary payroll payments.


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7. Development and activation

7.1. Develop intuitive strategiesto manage and/or mitigate the spread of disease and/or minimise further physical damage(especially during a pandemic).

Strategies include:

Transfer or relocation

In principle agreement/arrangement (sharingresources)

Temporary/ manualworkaround (alternative torelocating)

Change, suspend orterminate services, functionor process

Insurance (reputation risk)


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7.2. Management, staff/ volunteers and patient/ residents trainedin all aspects of emergency management/ business continuity:

(1) Escalation procedures, triggers/ business rules, etc.?

(2) Horizontal evacuation to another part of the same floor, but within the same building?

(3) Vertical evacuation to different floors of the same building?

(4) Full scale/ whole site/ building evacuation to pre-designated assembly areas located outside the building, including managingheadcount and communications?

(5) Full scale relocation to alternate locations/ facilities, including transportation and alternate transport route selection?

(6) Stay and shelter-in-place?

(7) Talking/ interacting with the media/ press, local radio stations, etc.?

(8) Discharge of non-critical patient/ residents to their own home/ families?

(9) Dealing with the injured and/or the dead, including communications with next-of-kin/ families?

Consider the following:

Clear understanding ofprocedures/ business rules.

Understand the duration forhorizontal and verticalevacuations for differentcategories of patient/residents.

Basic strategy for theevacuation of dependent orvery high dependency patient/residents may be to movethem on their bed or in awheelchair, to a safer area onthe same floor.Considerations will need to begiven to any requirements forcontinuing treatment or caree.g. high care, etc.

Each person must beaccounted for. If you have

more than one assemblypoint, need to ensureinformation is co-ordinated/synchronised between allassembly points forcompleteness (headcount).

Do not assume staff/volunteers know whichtransportation mode androute to take during a fullscale relocation.

Manage the media beforethey manage you.

Emergencies can lead to lossof life.


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7.3. What information regarding emergency, evacuation and relocation procedures should be included in your orientation programs for

new staff, volunteers and/or suppliers?

Are these procedures also communicated to your patient/ residents/ next-of-kin, especially when they first register? How often dowe need to update them with updated/ current information?

Orientation programs are a good

way to ensure that all new staff,volunteers and patient/ residentshave some relevant basicinformation.

7.4. Conduct education programs/ seminars on: (i) stress management; (ii) grief; and (iii) transfer trauma to staff, patient/ residentsand their facilities.

7.5. Conduct community education and equipping patient/ residents and their families, carers and support services to develop andknow how to implement their own disaster management plan.

Process/ procedure to promote inclusion of patient/ residents and/or people with disabilities in all stages of planning?

There is a need for inclusivecommunity education andassistance to enable patient/

residents and/or people withdisabilities, their carers andsupport services to develop andimplement their own emergencymanagement plan.

7.6. What support/ counselling/ welfare services are available to your patient/ residents and staff/ volunteers immediately after the

emergency (in-house or external), especially if there are emotional issues resulting from the emergency?

Physiological and emotional

impact on staff/ volunteer canaffect their work and ability tocontinue working in the stressfulenvironment of emergencies,especially when there is also ashortage of staff. Consider upskilling in-house staff as externalservices may not be immediatelyavailable.


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8. Identification of alternate facilities

8.1. Which alternate locations/ facilities have been identified, if stay and shelter-in-place is not appropriate? Are these alternatelocations/ facilities clearly documented in your plans?

Name of Alternate Facilities Contact Person/ Number Distance (KM) Travel Time

1.

2.

3.

4.

Do not leave the name andlocation of alternate facilitiesblank as to-be-advised (TBA) inyour plans.

When selecting a site, consider:

capacity

power, sewerage and water

communication

long-term availability

catering

access/ egress

proximity to transport

8.2. Process/ procedure for ensuring that the destination is appropriate to meet the needs of your patient/ residents?

Process/ procedure for ensuring that these alternate facilities/ locations will still be available at the time of relocation?

Agreements and commitmentsmay not be honoured in times ofemergencies.

8.3. Process/ procedure in place to notify alternate locations/ facilities that a decision has been made to evacuate patient/ residents to

their facility? How much advance notice is required?

Early notification would assistreceiving facilities to make allnecessary preparations to theiroperations to adequately caterfor your patient/ residents.


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8.4. Which local, state and/or federal authorities/ agencies should be consulted in your decision to either (i) relocate the patient/

residents or (ii) stay and shelter-in-place? Contact names and numbers listed in your emergency contact list?

Organisation Name Contact Person/ Number

1.

2.

3.

Who is authorised for making the final decision, whether to (i) relocate to another facility, or (ii) stay and shelter-in-place in existing facilities?

What are the ultimate triggers/ business rules for this decision to be made?

Trigger 1: Assumptions? Dependencies?



You have the sole responsibility

and accountability (duty of care)to your staff, patient/ residentsand 3rd parties to maintain asafe, secure and healthyenvironment under allcircumstances. The test would bewhat was reasonably practicablein the circumstances (seeOccupational Health and SafetyAct 2004)

Ultimately, the CEO may be thesole person who is required tomake this crucial decision. Alldecisions made may carry legalconsequences, especially afterthe event. As such, document allkey decisions made to avoiddisparity in facts and sequence ofevents.

TIME IS OF ESSENCE! If youwait too long to make the

decision, external help may notbe available and escape routesblocked/ unavailable/ unsafe.

An evacuation/ relocation may betriggered by a variety of causes.These may include:

Heat wave/ climate change.

Infrastructure failure.

Fire (internal/ external).

Power or other utilitiesfailure.

Flooding (internal/ external).

Gas leak.


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8.5. What written documentation confirms the commitment of these alternate locations/ facilities (e.g. an in principle agreement)? Is

the cost/ pricing agreed and documented?

Facility Name Agreement (Y/N) Cost Agreed (Y/N) Lead Time to Notify

1.

2.

3.

4.

Consider the length of time each patient/ resident may need to spend at these alternate location/ facility.

Consider road-blocks that may hamper your escape or movement to/ from your facility.

Consider registration procedures that may be imposed by authorities.

Third parties may be prevented

themselves in fulfilling theircontractual obligations to you,especially if the emergency iswide scale, affecting large areasor entire communities.

Challenges of receiving facilitiesinclude:

Mobilising staff/ volunteersto care for incomingevacuees.

Organising communityvolunteers to welcomeevacuee patient/ residents.

Providing a home-away-from-home.

Reducing transfer traumawhere possible.

Minimising disruption topatient/ residents of

receiving facility. Paperwork of evacuee

patient/ residents.

Return transportation(restoration, resumption).


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9. Resources for emergencies/ evacuations/ shelter-in-place

9.1. What critical shortages of medicines, food and other supplies are anticipated during a prolonged emergency? Understand currentstock of consumables and explore options for accessing adequate supplies/ inventories that are vital for your critical servicesand/or business processes. Consider the need to stockpile essential supplies in advance.

What are their contractual obligations to you?

Do your supplier contracts contain business continuity/ emergency management clauses? Suppliers have continuity plans?

Consider shortages of suppliesbecause of increased demandduring emergencies (i.e. cleaningsupplies, home-based services,etc).

Evacuation can be a time-consuming and resource-intensive process. As the numberto be evacuated rises, so doesthe time and resources it will taketo carry out the entire evacuationprocess.

9.2. What resources/ equipment are required to move patient/ residents in the event of a (i) partial (lateral, vertical); and (ii) full-scaleevacuation/ relocation? Review evacuation routes in all buildings and ensure that staff are aware of them.

Where is this equipment stored/ kept? Is the area clearly marked for staff/ volunteer access during an emergency? By whatmeans can staff/ volunteer access this equipment on a 24/ 7 basis?

What staff/ volunteer training is provided in the use of this equipment?

Process/ procedure for maintaining inventory and maintenance schedule documentation for this equipment?

Having the right/ properequipment operated by skilledstaff/ volunteers would greatlyassist in the evacuation/relocation process.

Patient/ residents with restrictedmobility, patient/ residents who

use wheelchairs and patient/residents confined to bed cannotnegotiate escape routes,particularly stairways, unaided.Patient/ residents undermedication may require staff/volunteer assistance, andpatient/ resident who aredependent on electrical/mechanical equipment for theirsurvival cannot always be

disconnected and moved rapidlywithout serious consequences.


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9.3. Are patient/ residents who require the use of this equipment clearly identified? If so, how - e.g. Care Plan, etc.?

Process/ procedure for ensuring that this information is regularly updated?

Regularly updating individual

patient/ resident records is vitalto ensure that key informationgoes with your patient/ residents,especially to the appropriatealternate facility duringevacuation/ relocation.

9.4. In what order of priority (triage) or sequence people (patient/ residents included) are fully evacuated from buildings? (Forexample, most critical evacuated first or least critical evacuated first)

Clear guidance developed about how to handle and deal with vulnerable/ medically dependent patient/ residents?

Time is of essence. If you waittoo long, you may not haveenough time to evacuate/relocate everyone, especiallywhen emergency services arealso stretched and/or the area isbecoming dangerous for anyoneto enter or pass through.

Because of the potential for riskto evacuees during movement,special attention should be paid

to planning for this aspect. Allappropriate risk control measuresshould be considered.

9.5. Process/ procedure to secure site/ location/ premises, if required, when evacuating/ relocating? Lockdown procedure? Leaving your premise unsecured/unattended may result in theft/looting. A lockdown is theprocess of controlling sitemovement and access both

entry and exit of people aroundbuilding in response to anidentified risk, threat or hazardthat might impact upon thesecurity of patient/ residents,staff and assets or, indeed, thecapacity of that facility tocontinue operating.


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9.6. How will you maintain each patient/ residents Care Plan during transportation and/or at the alternate location/ facility? Would it

be updated prior to relocation/ transfer?

Care plans and other relevant patient/ resident documentation in hard-copies? Or are they all electronic?

Process/ procedure in place to print off hard-copy documentation from computer/ IT systems regularly, e.g. end of week?

Minimum time taken to restore minimum IT services in your organisation, if there is full failure of IT?

For fully computerised

environment, develop operationalmanual procedures of printingout key information for eachpatient/ resident so that it caneasily follow the patient/ residentin the event of an emergency,without full reliance on the ITsystems. Computers may not beoperating during an emergencyto facilitate any printing. The timeto restore IT systems is variable.

9.7. Ensure that each patient/ resident is clearly identifiable before, during and after transfer/ relocation? How would you undertakethe identification/ tagging process e.g. coloured wrist-band, tracking device, etc.? Name tags for your staff/ volunteers?

Before transfer:

During transfer:

After transfer:

It is your responsibility to ensurethat all patient/ residents are allaccounted for during therelocation process, duringtransportation and at all alternatelocations/ facilities.

Consider the following:

Type of transportationrequired, recommendedtransferring and liftingtechniques, and staffing.

Fax the data sheets to thereceiving facility, if possible.Also, ambulances will needthis information for transport.

Have identification bands forall patient/ residents withname, specific requirements,etc. Put the family contactname and number on facesheet and identificationbands.

Have nametags for all staff.


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10. Transportation

10.1. What transportation resources have been identified (e.g. buses, vans, ambulance etc)?

Transportation Mode/ Organisation Agreement in Place (Y/N) Cost/ Pricing Agreed (Y/N)

1.

2.

3.

4.

Consider disruptions totransportation systems and/or theinability of suppliers to fulfil theirobligations/ commitment to youbecause of their own staffshortages and/or disruptions totransport routes. Do not relysolely on one transportationprovider/ source and routes.

Written documentation/agreement confirm thecommitment of transportproviders, ensuring that thevehicles are readily availablewhen needed.

10.2. Transportation/ escape (safe) route identified?

Transportation/ Escape Route Private/ Public Road? Risk Assessment

1.

2.

3.

4.

Routes clearly marked/ colour-coded in your plans and/or documented in your plans? Develop maps/ locations of evacuationroutes and description of how to get to a receiving facility for transport drivers.

Transportation needs may varybased on environmentalconditions e.g. road conditions

may have been altered by flood,fire, etc.

Do not assume that drivers knowhow to get to your plannedalternate location/ facility.

All vehicles should be fullyfuelled.


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10.3. Transportation resources/ requirements meet the needs of your patient/ residents (e.g. supine, wheel chair etc)? Identify and plan for special

needs patient/ residents such aspatient/ residents on dialysis andoxygen, patient/ residents inneed of special lifting equipment,etc.

10.4. How long will it take to fully evacuate all patient/ residents to all alternate facilities? How long will each patient/ resident be intransit?

Full Relocation (All residents) Ave. Travel Time per residentTransportation/ Escape Route Min. Time Max Time Min. Time Max. Time

1.

2.

3.

4.

Given the profile of your patient/ residents, can they survive the relocation journey on the transportation selected? Would it causepotential loss of life and/or substantial harm?

Individual planning could bedone and documented in patient/residents care plan. This islinked to the prioritisation doneduring the site evacuation

process.Issues to consider:

Unavailability of busescontracted to evacuatepatient/ residents.

Unreliability or lack of airconditioning in alternativetransportation.

Inadequate staff/ volunteers.

Longer-than-expected traveltimes, which require staff toration food and water.

Failure to transport somemedications, oxygencanisters and incontinencesupplies.

Dehydration, pressure soresand travel related illnesses,such as urinary tract

infections, experienced bypatient/ residents.

10.5. Process/ procedure for ensuring these agreements are kept current, especially in the event of a wide scale emergency/pandemic?

Keep contracts regularly updatedand reviewed as part of yourorganisations contractmanagement system/ process.


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10.6. What resources/ supplies are required to care for patient/ residents during transit (relocation) e.g. blankets, water, medicines,

toileting facilities, continence supplies etc.?

Relocation may not be an option

if you cannot secure sufficientresources/ supplies that wouldaccompany patient/ residents tothe alternate locations/ facil

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