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PeaceHealth Oregon Network Facilities PeaceHealth Sacred Heart Medical Center University
District PeaceHealth Sacred Heart Medical Center at RiverBend PeaceHealth Cottage Grove Community Medical Center PeaceHealth Peace Harbor Medical Center PeaceHealth RiverBend Annex PeaceHealth Medical Group Clinics and Urgent Cares PeaceHealth Hospice and Home Care PeaceHealth Labs
PHON CONTINUITY of OPERATIONS PLAN
Created: 9/19/2016
PHON Continuity of Operations Plan
PeaceHealth Oregon Network
Reviewed: XX/XX/XXXXImplemented: XX/XX/XXXXX
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PHON Continuity of Operations Plan
PeaceHealth Oregon Network
Table of Contents1. Purpose.....................................................................................................32. Scope........................................................................................................33. Objectives.................................................................................................34. Response Phase........................................................................................3
Activation of Hospital Incident Management team.....................................3Facility Assessment......................................................................................3Notification and Reporting..........................................................................4
5. Recovery Phase.........................................................................................4General Assessment.....................................................................................4Levels of Recovery.......................................................................................4Recovery Level Determination.....................................................................4Recovery Level Initiation.............................................................................6Post-Emergency Tasks.................................................................................6
Appendix 1 - Department Caregiver Member Contact Listing.......................8Appendix 2 – Department Damage Assessment Report..................................9Appendix 3 - Recovery Status Report...........................................................10Appendix 4 - Inventory of Hardware Equipment..........................................11Appendix 5 - Documentation of Business Recovery Expenses......................12Appendix 6 – Standards for Incident Documentation and Structure............13Appendix 7 – Incident Response Guides.......................................................14Appendix 8 – Recovery Plan Coordination....................................................15
Plan Coordination......................................................................................15Coordination with Local, State and Federal Emergency Agencies...........15Annual Plan Reviews and Updates............................................................15
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PHON Continuity of Operations Plan
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1.PurposeThe plan sets policies, procedures, and organizational structure for response to events that are of sufficient magnitude to cause a disruption of all or portions of the Hospital operation and management. The plan outlines the roles and responsibilities of operational groups, and personnel during these events. Since an event may be sudden and without warning, these procedures are designed to be flexible in order to accommodate events of various types and magnitudes.
2.ScopeThis plan is written to globally address business continuity at the Facilities located in the PeaceHealth Oregon Network.
3.ObjectivesThis plan seeks to accomplish the following:
Minimize the number of decisions which must be made during a disaster.
Identify the resources needed to execute the actions defined by the plan.
Identify actions to be undertaken by pre-designated teams. Comply with applicable legislative policies, regulatory
requirements and directives. Define the process for testing and maintaining this plan and
training Caregivers. Regulatory and contracted obligations Reputation of or confidence in the entity
4.Response Phase
Initial response to a disaster or emergency situation will follow this plan. Once the plan has been initiated, the Incident Commander will focus on the operational period and initiate the PHON Continuity of Operations Plan as needed.
ACTIVATION OF HOSPITAL INCIDENT MANAGEMENT TEAMIAP Quick Start Incident Action Plan (IAP) Quick Start [Word] [PDF]
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PHON Continuity of Operations Plan
PeaceHealth Oregon Network
FACILITY ASSESSMENT
The Incident Commander or designee will perform a quick assessment of damage to the facility, equipment, power and water supplies, furniture and if possible, an assessment of on-site critical data and vital records.If needed the Incident Commander will complete a damage assessment to determine whether or not the site can self-recover once the “all clear” has been given by the proper authorities. All reports will be communicated to the Hospital Incident Commander or designee.
HICS 251
Facility System Status Report
[Word]
[PDF]
NOTIFICATION AND REPORTING The Incident Commander or designee will notify appropriate
personnel, agencies, and governmental and non-governmental agencies as required.
The Incident Commander will report the status at intervals requested by regulatory and governance structures using Recovery Status Report form (see Appendix 3: Recovery Status Report).
5.Recovery PhaseFor the purposes of this Plan, “recovery” is defined as the restoration of critical business functions in the shortest possible time to protect and preserve safe patient care and revenue as well as return the processes and support functions to operational stability following an interruption or disaster.
GENERAL ASSESSMENT
The objective of an assessment is to initiate the proper recovery response to conditions resulting from the emergency situation. Duties performed during the Assessment Phase include:
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Assess the resulting conditions after the immediate threat is over.
Select the recovery procedure to initiate. Set the selected recovery procedure in motion.
LEVELS OF RECOVERY
The recovery phase starts when the immediate threat to human life has subsided. The department will implement the prioritized actions required to return the patient care and support functions to operational stability following an interruption or disaster. After an event where business operations have been shut down, the entire environment may be dangerous. The first recovery step is to secure the facilities. Only after the environment is safe can restoration efforts begin, followed by an orderly reopening of normal business operations.
RECOVERY LEVEL DETERMINATION
Based on reports the Hospital Incident Commander will determine a level of recovery using the guidelines illustrated in the following chart.
Level DurationDecisionPoints
Instructions for Caregivers
1 0-60 minutes
Stay in place if it is safe to do so. If lighting inadequate, open blinds and doors (if safe) and deploy headlamps/flashlights. Perform tasks that can be safely accomplished with available utilities.Relocate patients and visitors as needed and communicate your intent to return to normal operations as soon as possible. Keep patients and visitors informed regarding your progress. If patients elect to leave and return when the department is fully operational accommodate those requests making arrangements to
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Level DurationDecisionPoints
Instructions for Caregivers
reschedule the appointment(s)
Level 1 recovery procedures are intended to return operations to the normal processing mode within one (1) hour after the occurrence of a disruption.
The Alternate Site is not needed.2 Between 1 -
4 hoursReschedule patient appointments and begin relocating caregivers to alternate work areas, if available, or consider sending caregivers to other units that needs staffing.
Level 2 recovery procedures are intended to return operations to the normal processing mode within four (4) hours from occurrence without moving operations to the Alternate Site.
3 Between 4 – 24 hours
Evacuation of the facility or part of the facility. Have all caregivers move to an alternate work area.
Level 3 recovery procedures are intended to return operations to the normal processing mode within 24 hours from occurrence without moving operations to the Alternate Site.
4 Between 24 – 72 hours
Level 4 recovery procedures are intended to return operations to the normal processing mode within 72 hours from occurrence. It is possible, depending on the type of disaster that some operations
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Level DurationDecisionPoints
Instructions for Caregivers
may need to be relocated to the Alternate Site.
The HIMT will consider alternate locations and relocation guidelines.
5 As directed by the Hospital Incident Commander or designee
Catastrophic recovery procedures (Level 5) are designed to allow the facility to restore operational functions after experiencing a catastrophic (worst case) situation. In these circumstances, the facilities have been rendered unusable and Alternate Sites must be utilized.Coordinate with Hospital Incident Management Team regarding alternate locations, relocation guidelines and business operations following relocation.
RECOVERY LEVEL INITIATION
All Recovery Level decisions will be approved by the Hospital Incident Commander or staff before any recovery level, beyond Level 1, is initiated.Once the recovery level has been selected and approved, the Incident Commander will execute the appropriate recovery procedures. The three-day maximum recovery period creates a fail-safe condition. Up to 48 hours may be required to set up operations at an alternate site, attempts to recover without going to the alternate site require close scrutiny, especially at the end of day 2 (depending upon where the weekend falls within the recovery cycle).The HIMT will utilize the Supply Chain Business Disruption Readiness procedures and contracts found at http://teams/site/sccm1/SCBDR/default.aspx as needed.
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PHON Continuity of Operations Plan
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POST-EMERGENCY TASKS
The Incident Commander is responsible for directing departments to complete the post-emergency administrative tasks. Responsibilities will differ depending upon the nature of the emergency and whether recovery is accomplished at the Primary Site or at the Alternate Site. Consider the following:
1. Using Appendix 4: Inventory of Hardware Equipment, complete a full inventory of resources and indicate the condition of each item.
2. Continue to provide timely updates to patients and suppliers regarding the status of the operation and expected recovery times.
3. Gather written information to support insurance claims for injury or damages suffered by staff members, equipment, software, supplies, facilities, etc. All claims information is to be provided to Risk Management. Date of loss, type of loss, description of loss and contact information will need to be collected for accurate filing using Appendix 5: Documentation of Business Recovery Expenses. The HIMT Finance Section Chief to utilize all appropriate HICS forms to properly document the gathered data.
4. Procure supplies, contact supply chain for assistance as needed.
5. Daily Department reports will be sent to the Hospital Incident Commander or designee on recovery and restoration status.
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PHON Continuity of Operations Plan
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Appendix 1 - Department Caregiver Member Contact Listing
DEPARTMENT:
Incident CommanderName, Title - INCIDENT COMMANDERName, Title - ALTERNATE
Note: Unless otherwise specified, the Incident Commander is the person responsible for initiating the contingency and recovery efforts.
Caregiver MembersThis section is to be updated on a monthly basis. Information Valid as of: mm/dd/yyyy
First Name
Last Name Job Title
Work Phone Email Address
Dept.Facili
ty
Dept.Facili
tyNum
Dept.Num
Pay Organization
Supervisor
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PHON Continuity of Operations Plan
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Appendix 2 – Department Damage Assessment Report
DEPARTMENT NAME:
Date Occurred: Time Occurred:Nature of Emergency
Damage Resources Estimated Restoration TimeItem Vendor Day Hours
Application Systems Impacted:
User Departments Impacted:
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Original report shall be returned to Hospital Incident Management Team for Document Retention purposes. Copies of the report will be distributed to department Directors/Managers
Appendix 3 - Recovery Status Report
DEPARTMENT NAME:
INCIDENT COMMANDER:
Alternate Manager
Caregiver Completing Report:
Title
Date / Time:
Subject / Location:
Findings/Observations/Recommendations:
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Original report shall be returned to Hospital Incident Management Team for Document Retention purposes. Copies of the report will be distributed to department Incident Commanders.
Appendix 4 - Inventory of Hardware Equipment
DEPARTMENT NAME:
All columns of this file should be completed prior to an event, and should include all hardware (computers, telephones, printers, etc.) and other supplies (desks, filing cabinets, etc.). During an event the final column “Condition after Event” is filled in. This form may be used for replacement, insurance, warranty, or other purposes.
Qty.
Item Description
Name, Model
Reorder No
Owned or
Leased
Vendor
Contact
Where
Used
Approx.
Replace Cost
Emergency
Replace Lead Time
Condition
After Event
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Original report shall be returned to Hospital Incident Management Team for Document Retention purposes. Copies of the report will be distributed to department Incident Commanders.
Appendix 5 - Documentation of Business Recovery Expenses
DEPARTMENT NAME:
Date Item Cost
Method of Payment
(Cash / Company CC / Personal CC
/ Personal Check)
Approved By Comments
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Original report shall be returned to Hospital Incident Management Team for Document Retention purposes. Copies of the report will be distributed to department Incident Commanders.
Appendix 6 – Standards for Incident Documentation and Structure
Adequate documentation of ALL aspects of the incident are necessary for regulatory agencies, reimbursement, and cost containment, cost and service recovery in the shortest possible time. The PHON COOP plan will utilize the HICS forms and procedures below.
HICS Guidebook [PDF] Download HICS 2014 materials to CD APPENDICES Appendix A Acronyms [PDF] [Word
] Appendix B Glossary [PDF] Appendix C Hospital Incident Management Team [PDF] [Word
][Visio
]Appendix D Candidates for HICS Command/General Staff
Positions [PDF] Appendix E Incident Planning Guides
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Appendix F Incident Response Guides Appendix G Job Action Sheets Appendix H HICS Forms Appendix I Resources and References [PDF] Appendix J HICS 2014 Project Organization [PDF] GRAPHICS HICS Logo [JPG] Operations Section [JPG] [Visio
] Planning Section [JPG] [Visi
o] Logistics Section [JPG] [Visio
] Finance/Administration Section [JPG] [Visio
] HICS External Communication Figure [JPG] [Visio
] FAQ FREQUENTLY ASKED QUESTIONS (FAQ)
Appendix 7 – Incident Response GuidesThe links bellow will lead to the initial Incident Response Guides for common incidents, giving suggested direction to the HIMT for various operational periods.
All Incident Response Guides [Word] [PDF]
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Active Shooter [Word] [PDF]Chemical Incident [Word] [PDF]Earthquake [Word] [PDF]Evacuation, Shelter-in-Place, & Hospital Abandonment
[Word] [PDF]
Explosive Incident [Word] [PDF]Hostage or Barricade Incident [Word] [PDF]Infectious Disease [Word] [PDF]Information Technology (IT) Failure [Word] [PDF]Mass Casualty Incident [Word] [PDF]Missing Person [Word] [PDF]Radiation Incident [Word] [PDF]Severe Weather with Warning [Word] [PDF]Staff Shortage [Word] [PDF]Tornado [Word] [PDF]Utility Failure [Word] [PDF]Wildland Fire [Word] [PDF]
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Appendix 8 – Recovery Plan CoordinationIt is the responsibility of each Disaster Recovery Plan member to remain aware of any imminent natural disasters being forecast.
PLAN COORDINATIONIn the event that surface streets/highways become impassable the HIMT should initiate communication to the Lane County EOC
COORDINATION WITH LOCAL, STATE AND FEDERAL EMERGENCY AGENCIESThe Office of the Emergency Management Coordinator will provide copies of this recovery plan to the appropriate Local, State and Federal Emergency Departments or Command Centers and coordinate efforts with such agencies to leverage additional support during a large-scale emergency.
ANNUAL PLAN REVIEWS AND UPDATESThis COOP will be reviewed and updated yearly showing all revisions and additions made throughout the year.
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