the following area is where downtime procedures will be

UT Southwestern Medical Center Confidential Dated Material

Generic Department Business Continuity Plan

The following area is where Downtime Procedures will be documented once they are identified and/or written.

The Critical Functions Template on the following pages is to be used to identify those functions that are critical to the day-to-day operations of your department. Please make numerous copies of the template, and document the necessary information for each critical function.

Printed Date: 4/10/2023document.doc3



Critical Functions Template #____

Complete a page for each critical function within your department/clinic. (A critical function is defined as something the department depends on to operate and the department is nonfunctional without this.)

Department Name:

Critical Function:

Description of Function or Process:

Number and type of personnel:

Do other depts. depend on the success of this function in order to perform other critical functions? If so, please check the departments:

□ Accounting □ Physical Plant □ Other : __________

□ Human Resources □ Clinics □ Other : __________

□ MSRDP □ Budget □ Other : __________

□ Info Resources □ Materials Mgt. □ Other : __________

Check any systems or applications that are required to support the critical function.

□ OAS (HRMS, PO) □ Answering Service

□ IDX □ Epic

□ Cerner □ OACIS/CDR

□ EFT □ Other : ______________________

□ PACS □ Other : ______________________

□ CIMS/Snips □ Other : ______________________

□ Case Manager □ Other : ______________________




The following pages document the pre-approved downtime procedures for the

various applications listed above. Some applications or functions have more

than one pre-approved version. Please select the version that most mimics the

procedures that you would follow. Departments are strongly urged to adopt

these procedures in their own departments. If you find that your department’s

downtime procedures must be different (or there are no listed procedures for

your application), document your procedures in electronic form (preferably

Word) and send to the department of Business Continuity. Procedures should

address system outage of up to 5 business days. Please contact Business

Continuity at 214-648-0727 if you have any questions.




Generic Business Procedures

ALTERNATIVE WORK LOCATIONS

It is likely that a disaster may require the physical relocation of resources and the establishment of alternate work sites. This may require relocation within UT Southwestern's current facilities, other locations, and working from home (as is mentioned in another section of this Business Continuity Plan). Department management will be required to make decisions based on available space and relocation of its resources within its existing work areas if they are deemed safe and in appropriate conditions. Any additional space and relocation need decisions, beyond that of the departments' normal physical work area(s), will be made at the time of disaster by Executive management.

Complete loss of the facility

□ Not Applicable

□ Version 1

1. Notify staff of event and if there is a temporary site to report to for daily work functions. If a temporary work site for staff is unavailable, designate some or all staff to work from home to handle daily tasks that support business functions. Refer to Work From Home.

2. If staff has a temporary work site to report to, then call Purchasing (main number is 86040) to purchase the standard list of supplies Refer to Supply List.

3. If staff is designated to work from home, staff will access work forms, databases, applications and e-mail via the Virtual Private Network (VPN) and the “O” and “S” drives as available. Internet access is required to use the VPN; however, staff utilizing AOL on their home computers will not be able to access VPN. Voice mail will be retrievable if the phone lines are working. Refer to Work From Home.

4. Direct staff as to those daily functions that should be conducted during this time. Remain in communication with the Team Leader and the Business Continuity Coordinator (BCC Contact Info) throughout the duration of the disaster process.




□ Version 21. Notify Telecommunications to proceed with the transferring of the phone system over

to the alternate location. Selection of an alternate site will require the availability of telephones designed for call center activity.

2. An Interim Greeting will be used to allow appropriate time for staff to reach the alternate location and begin answering the phone lines. Once staff has safely arrived at the alternate location, the greeting will be changed to the Business Hours Greeting to address callers who receive a busy signal.

3. Supervisors will proceed with notification of event to staff with reporting instructions.

4. Assign one member to retrieve phone messages from the answering machine.

5. As staff arrives at the alternate location(s), each individual will be instructed to sign-in on the Employee Sign-in Sheet in Campus Forms upon arrival.

□ If your procedures differ from that above, send your own procedures electronically to the Office of Business Continuity.




APPLICATIONS

OAS

□ Not Applicable

□ In the event OAS is unavailable, follow the steps below:

1. Obtain all Necessary Clinical Forms.Several forms that you’ll need for your clinic/department should be in Campus Forms. There may also be a CD in the envelope flap in the front of this manual that contains a copy of all necessary forms. If so, load the CD into a PC and print the necessary forms. If a CD is not found in the manual, refer to Supply List. Note the source or location where forms can be found and contact the area to print the forms. In example, “Printing Services” may be noted on the list as the source. If the form is not listed on the Supply List, contact Administration for further guidance.

2. Clinical Supply / General Stores OrdersAll general supply orders that would normally be ordered through OAS must be entered on a paper Interdepartmental Requisition (IDR) form in Campus Forms and either taken to General Stores located in the Service Building (X02.104) at 4600 Harry Hines Blvd., or faxed to 86077 while the system is down. After the system is restored, the General Stores staff will enter the information into the system and charge the appropriate account listed on the IDR form. Refer to Supply List for a list of common supplies.

3. Requisition (REQ) Orders Requisition orders to outside vendors will be placed manually with the vendor by telephone. A purchase order number can be obtained by calling Office of Purchasing (main number is 86040). Clinics/departments will be responsible for placing manual orders totaling less than $100 in value.

Procurement Cards can also be used to order supplies during system downtimes. These cards are issued to a specific person in each department and can be obtained by contacting Materials Management Administration (main number is 86040).

4. Gas Cylinder OrdersAll gas cylinder orders that would normally be ordered through OAS must be entered on a paper Interdepartmental Requisition (IDR) form in Campus Forms and either taken to Gas Cylinders located in the Service Building (X01.002E) at 4600 Harry Hines Blvd. or faxed to 86021 while the system is down. After the system is restored, the Gas Cylinder staff will enter the information into the system and charge the appropriate account listed on the IDR form.




5. Maintain Copy of Forms for Future Data EntryDuring the time the OAS system is inaccessible, supervisory staff will maintain a copy of all downtime forms to be input into OAS once the system is recovered and ready for data entry. Please note in the procedures above, which department will be responsible for entering the downtime data into the system once restored.





BILLING

IDX

□ Not Applicable

□ Issue a steno pad (which will be numbered), and a copy of the Patient Telephone Calls Script to staff for use when answering incoming calls from patients and third party payers. This will include the instructions for taking messages (e.g., identifying all the pertinent and necessary elements to capture in order to properly return calls once the IDX system has been restored).

If possible, retrieve the data entry that was completed for at least one day prior to the event. Once IDX data is restored you will need to re-enter this data. More often than not, the date the system is restored to is several days prior to the event.

□ 1. Obtain all Necessary Clinical Forms.Several forms that you’ll need for your clinic/dept. should be in Campus Forms. There may also be a CD in the front of this manual that contains a copy of all necessary forms. If so, load the CD into a PC and print the necessary forms. If a CD is not found in the manual, refer to Supply List. Note the source or location where forms can be found and contact the area to print the forms. In example, “Printing Services” may be noted on the list as the source. If the form is not listed on the Supply List, contact Administration for further guidance.

2. Maintain Daily Records Perform the following on a daily basis during the IDX system downtime.

Scheduled Appointments:1. Record all new patient registrations and updates on the Registration Form.2. Have all patients complete the HIPAA Notice of Privacy Practice and Patient

Registration and Consent for Treatment forms.3. Refer to the daily clinic roster for a list of patients scheduled. Mark the patient

on the roster upon arrival in the clinic. If no printed list is available, the Registration Forms may serve as the record of appointed patients for the day.

4. Use Sign-in Labels to record arrivals.

Walk-In Patients: (if applicable)1. Record all new patient registrations and updates on the Registration Form.2. Make a copy of the patient's insurance card.3. Have all patients complete the HIPAA Notice of Privacy Practice and Patient

Registration and Consent for Treatment forms.4. If the patient has not been seen in an UTSW Ambulatory Services Clinic

before, call Medical Records (82498) to make a new chart.5. If the patient has been seen in an UTSW Ambulatory Services Clinic before,

call Medical Records (82498) to request the chart.




6. Use Sign-in Labels to record arrivals.7. Complete an Encounter Form for the visit.8. Keep all forms for entry once the system is restored.

Requests for New Appointment:1. Record appropriate patient information on the Appointment Schedule Log.2. Once the system is restored, call the patient and complete the appointment

schedule.

Use Downtime Log to record other important activity .

3. Recording and Depositing Cash and ChecksThe clinic staff personnel will complete a manual Pegboard Journal and a Daily Transaction Summary for all transactions each day. The Pegboard Journals, Receipts (in place of batch proofs and 990 report), Daily Transaction Summary, Change Fund Bag, and Money Bag will be delivered to the appropriate Business Services Cashier’s Office by the on-campus clinic before 6:00 pm each evening for recording and depositing. Off-site clinics will deliver their Pegboard Journals, Receipts, Daily Transaction Summary, Change Fund Bag, and Money Bag to the Aston Center Business Services Cashier’s Office via courier by the start of the next business day.

4. Process Credit Card Payments

In the event the credit card processing system is down due to the disaster, an authorization code must be obtained manually by telephone from the credit card company. Approved credit card payments should then be entered on the Pegboard Journal. If all types of phone lines are down and an authorization code is unobtainable, no credit card payments will be accepted until the restoration of the credit card processing software system.

5. File Copies of ReceiptsA copy of the Pegboard Journals will be given to the clinic staff personnel responsible for the deposit by Business Services at the end of the day and kept by the clinic supervisory staff until the system is recovered and ready for data entry. Retain a signed copy of the Daily Transaction Summary as well.

6. Maintain Copy of Forms for Future Data EntryDuring the time the IDX system is inaccessible, the original downtime forms will be placed in the patient’s medical record, and a copy of the forms will be kept by the clinic’s supervisory staff. These forms will be used for input into IDX once the system is recovered and ready for data entry.





COMMUNICATIONS

Call Trees or Department Personnel Contact Information ListsCommunication will be very important in a disaster situation. Individuals will need to be informed of the status of a situation, instructions, or for other purposes. Department management should produce a list of all department personnel and their emergency contact information away from work. This list should be updated regularly, distributed accordingly, and maintained separately in an area(s) where it will be readily available and also properly secured against privacy/ information security breaches. For now and due to privacy and information security potential issues, the contact/call tree list is formally excluded and not published as part of the Business Continuity Plan.

Telecom

Provide Phone Message Support (3 options, pick 1)

□ Not Applicable

□ Contact Telecommunications to ensure that phone service is covered if the business disruption/disaster affects the functionality of these lines. Provide assistance in obtaining new phone and fax numbers for affected clinics/departments, as necessary.


Loss of Phone Connectivity

□ Not Applicable

□ This box should be checked if any of the three below apply.

1. Cell phones should be used as available.

2. In the event that there are available handheld radios, then these radios will be dispersed to the appropriate locations. If no radios are available within the department, then contact the BCC Office (BCC Contact Info) and best efforts will be made to issue radios to the appropriate satellite locations as listed below:

3. If no radios are available, runners will be used until radios become available. These phone procedures supersede those listed within Work Area Restoration.





HUMAN RESOURCES

In the event of a disaster, and if normal electronic operating procedures cannot be utilized due to a loss of computer access or some other deficiency in the process, the following tasks can be completed as follows:

Over-time or Compensatory Time Pay: Employees may be requested to work more than their normally scheduled hours. However, a number of employees are not designated to receive over-time or compensatory time incentives due to the nature of their normal job functions. In a time of disaster recovery, each department can designate an employee to receive over-time or compensatory time pay if it is deemed necessary to aid in the recovery of the department operations. The department head will have to request authorization for an employee to receive over-time or compensatory time pay through a formal request to the Human Resources Director. In this request, the department should indicate the following-

A. Employee nameB. Identification number C. Current Position Title and ClassificationD. Reason to allow over-time compensationE. Dates for which this request will be in effect

Badge Requests: During a disaster, employees may need to be reissued identification badges to allow them into areas they are not normally allowed or to re-issue badges that are lost or destroyed. The department head or designee will make formal requests for badge reissue or changes to access through the Human Resources Office and University Police. The following information is needed in this request and sent to Human Resources-

A. Employee nameB. Identification numberC. Current Position Title and ClassificationD. Reason for reissuing badge or what change to badge is necessaryE. Date needed

Employee Contact Information: Events during a disaster situation may require employees to move locations or evacuate. Updating the contact and location information is key to ensuring the information can be provided to employees and pay can continue to be delivered in a timely fashion. Two methods for updating this information will be followed:

A. Primary- If data centers are operational, employees will utilize the iAim system online. Employees will need VPN access and will be update as soon as possible.




B. Secondary- If data center is not accessible, or the employee cannot access iAim online, then the employee will contact his/her department administrator with this information. The Department will coordinate all changes and provide them to HR and Payroll as needed.

Alternative Staffing Plans: In the event that a disaster impacts multiple departments, staffing shortages or needs may arise amongst the affected departments. Various situations as listed will be addressed in the following manner:

A. Temporary Services- If temporary employees are necessary for a department to maintain its critical functions, a formal request to Southwestern Temps (through use of the Temporary Employee Request Form) will be required. Employees will be provided on a priority basis determined by UTSW Administration, Human Resources and Southwestern Temps.

B. Staff Re-Assignment- If a department requires additional or replacement staffing, temporary staffing from other unaffected departments can be utilized. A formal request between the Departments involved and Human Resources will be need to occur to ensure appropriate notification and pay.

C. Work From Home- It is not currently the policy for UTSW staff to work from home. A decision would have to be made by UTSW management for that to change. If this policy changes, each department that would like their employees to conduct operations from home would need to make a formal request to Human Resources. The request should contain the following:

1. Employee name2. Identification number3. Current Position Title and Classification4. Reason for working from home5. Dates this will be in effect

Employee Benefits: After a disaster, employees will still need access to their benefits. The following areas will be handled as described:

A. Leave/Time Off- employees may still have access to their leave/vacation benefits. All departments will continue monitoring and tracking this usage of leave/time off through the paper form available through Human Resources.

B. Injury- Departments will document all employee injuries in the same manner as during normal work conditions except that the documentation will be manual through use of the human resources injury documentation forms.

Employee Assistance ProgramMajor events or disasters can trigger a “trauma response”- a temporary reaction to a serious incident. The incident can shatter employee’s sense of safety and well being and temporarily impairs their ability to function normally. The Employee Assistance




Program (EAP) provides debriefing and/or counseling, to talk about how the incident affected your employees.

If your employees demonstrate the following symptoms: Numbness. Characterized by withdrawal from others, depression or emotional

flatness. These signs may be accompanied by problems with concentration at work.

Hyperarousal. Characterized by irritability, flashbacks to the incident, nervousness, extreme emotion s, nightmares, and being easily startled.

Please contact the EAP offices at (214) 648-5330 or (800) 386-9156 for further information. Or, you may contact them by e-mail at [email protected].


mailto:[email protected]



PAYROLL

In the event of a disaster, electronic back up of the payroll systems will be utilized. However manual time-keeping methods should be completed if the department utilizes the following tracking software.

ADP or Kronos

□ Not Applicable

□ In the event the time clocks are down, all applicable staff should use the Employee Sign-in Sheet in Campus Forms to record in/out times for shifts and lunch breaks.





PROCUREMENT

Use of Physical Plant, General Stores, or Purchasing Department Services

In the event of a disaster, normal operating procedures should be followed to obtain supplies, services, or other items requested of Physical Plant, General Stores or Purchasing. However, should normal operating procedures not be available due to loss of computer access or some other deficiency in the process, the following procedures should be followed:

Submit your request to the respective department using a hard copy request form. You should make copies of any online forms that are normally used and place these hard copies in your Business Continuity Plan manual in the “forms” section in advance. You will need to physically deliver the request(s) to the respective office yourselves. Courier service may be used if available and if timing is not an issue. Manual tracking will be in place by respective department(s). You should take the initiative to follow up on the status using the telephone, radio, or available cell phone if response to request is delayed beyond that agreed upon or estimated. The respective departments will need to prioritize requests as they are received. Telephone requests may be accepted based on the urgency and importance of the request and the traffic involved. Use your best discretion on placing the request via telephone versus submitting the request in hard copy form. Do not take the initiative to work around these procedures unless instructed to do so. Cooperation and communication will be key in the success of your request.




REVENUE MAINTENANCE

Recording/Depositing Cash and Checks

□ Not Applicable

□ Batch out register and deposits with appropriate cash register log for all transactions each day. The Register Journals, Receipts (in place of batch proofs and 990 report), Daily Transaction Summary, Change Fund Bag, and Money Bag will be delivered to the appropriate Business Services Cashier’s Office by the on-campus clinic before 6:00 pm each evening for recording and depositing.

□ Complete a manual Pegboard Journal and a Daily Transaction Summary for all transactions each day. The Pegboard Journals, Receipts (in place of batch proofs and 990 report), Daily Transaction Summary, Change Fund Bag, and Money Bag will be delivered to the appropriate Business Services Cashier’s Office by the on-campus clinic before 6:00 pm each evening for recording and depositing. Off-site clinics will deliver their Pegboard Journals, Receipts, Daily Transaction Summary, Change Fund Bag, and Money Bag to the Aston Center Business Services Cashier’s Office via courier by the start of the next business day.


Process Credit Card Payments

□ Not Applicable

□ In the event the credit card processing system is down due to a business disruption, an authorization code must be obtained manually by telephone from the credit card company. Approved credit card payments should then be entered on the Registry Journal. If all methods of phone communications are down and an authorization code is unobtainable, no credit card payments will be accepted until the restoration of the credit card processing software system.

□ In the event the credit card processing system is down due to a business disruption/disaster, an authorization code must be obtained manually by telephone from the credit card company. Approved credit card payments should then be entered on the Pegboard Journal. If all methods of phone communications are down and an authorization code is unobtainable, no credit card payments will be accepted until the restoration of the credit card processing software system.





RECORDS MANAGEMENT AND RECOVERY

Electronic Data Back- Up Procedures

Please refer to the UT Southwestern Medical Center at Dallas Security Policy sections 200-15 - Backup and Recovery, 200-23 - Information Resources Contingency Planning, and the File Back-Up Guide. These are all on UT Southwestern’s Intranet IT Website under Information Security (Back Up File Guide and Security Policies). Management and other department personnel will be expected to be knowledgeable, understand, and comply with these policies. This knowledge, understanding, and compliance will greatly enhance any opportunities for a successful continuation of business and recovery should a major disaster occur in the future. Enforcement and compliance is mandatory.

Transcription Services

□ Not Applicable

□ Clinics that use transcriptions services need to contact these businesses to inform them of the expected downtime.

□ Non-transcribed tapes must be marked with the clinic name, physician name, and the date. These tapes will be placed in a locked drawer or cabinet for safekeeping. Portable dictation equipment, batteries, and tapes should be procured.


Pharmacy Orders

□ Not Applicable

□ Campus Pharmacy orders are placed with the pharmacy by hand delivering or faxing (214-648-2652) a completed order form to the Campus Pharmacy located on the ground floor of the Aston Center. The necessary order form is in the Clinical Forms section of this manual. The department and/or clinic account number and standing purchase order number must be included on the form.


Collect Data Entry

□ Not Applicable




□ Retrieve the data entry that was completed the day prior to the disaster and store in a secure area. It is best to store several days work if possible. You will re-enter the data once the system(s) is restored.


OACIS/CDR

□ Not Applicable

□ This system is a central repository of a patient’s medical history. In the event this is the only application that is unavailable, then the originating application should be reviewed to find the desired information. This system is also used to view labs, transcription notes, visit types, and radiology. In the event the system is down, IDX BAR and IDX SCHED would be consulted for invoices. If all 3 systems are down, EPIC/UT SMART would be consulted, and appointments and registration information could be viewed. If all systems are down, and paper record is not available, incoming overlays and duplications would be placed on a excel spreadsheet and worked later. Since data is electronically transferred into this application from a variety of others, there are no manual procedures to follow or forms to be used until the system is restored.


Cerner

□ Not Applicable

□ The following procedures will be utilized whether it is a scheduled or short-term (less than one day) computer downtime, or has been determined to be longer than one day (such as your facility or the Data Center has suffered significant damage).

1. Laboratory Requests and Reports All Lab Requests will continue to be processed using the Microbiology

Laboratory Requisition Form.

Old Lab Results may be obtained by calling Medical Records and obtaining the chart.

New Lab Results may be obtained by calling the lab.

2. Radiology Requests and Reports

All Radiology Requests will continue to be processed using the Radiology Order Form.




Old Radiology Results may be obtained by calling Medical Records and obtaining the chart.

New Radiology Results may be obtained by calling the Accurate verbal report number at 972-889-2251 (NOTE: Caller must have user-ID and password in order to access reports). If the results have not been transferred to Accurate, then contact Radiology (83711) for the results.


PACS

□ Not Applicable

□ In the event the PACS system is unavailable, contact Radiology (83711) for the availability of images.



the following area is where downtime procedures will be

Health & Medicine