Peacehealth Oregon Network Facilities

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

Reviewed: XX/XX/XXXX

Implemented: XX/XX/XXXXX

Table of Contents

1.Purpose

2.Scope

3.Objectives

4.Response Phase

Activation of Hospital Incident Management team

Facility Assessment

Notification and Reporting

5.Recovery Phase

General Assessment

Levels of Recovery

Recovery Level Determination

Recovery Level Initiation

Post-Emergency Tasks

Appendix 1 - Department Caregiver Member Contact Listing

Appendix 2 – Department Damage Assessment Report

Appendix 3 - Recovery Status Report

Appendix 4 - Inventory of Hardware Equipment

Appendix 5 - Documentation of Business Recovery Expenses

Appendix 6 – Standards for Incident Documentation and Structure

Appendix 7 – Incident Response Guides

Appendix 8 – Recovery Plan Coordination

Plan Coordination

Coordination with Local, State and Federal Emergency Agencies

Annual Plan Reviews and Updates

1. Purpose

The 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. Scope

This plan is written to globally address business continuity at the Facilities located in the PeaceHealth Oregon Network.

3. Objectives

This 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 team

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.

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 Phase

For 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:

 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.

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 as needed.

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.

1. 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.
2. Procure supplies, contact supply chain for assistance as needed.
3. Daily Department reports will be sent to the Hospital Incident Commander or designee on recovery and restoration status.

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Appendix 1 - Department Caregiver Member Contact Listing

Incident Commander

Name, Title - INCIDENT COMMANDER

Name, Title - ALTERNATE

Note: Unless otherwise specified, the Incident Commander is the person responsible for initiating the contingency and recovery efforts.

Caregiver Members

This section is to be updated on a monthly basis. Information Valid as of: mm/dd/yyyy

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Appendix 2 – Department Damage Assessment Report

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

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

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.

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

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.

Appendix 7 – Incident Response Guides

The links bellow will lead to the initial Incident Response Guides for common incidents, giving suggested direction to the HIMT for various operational periods.

Appendix 8 – Recovery Plan Coordination

It is the responsibility of each Disaster Recovery Plan member to remain aware of any imminent natural disasters being forecast.

Plan Coordination

In 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 Agencies

The 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 Updates

This COOP will be reviewed and updated yearly showing all revisions and additions made throughout the year.

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