1. No category

BUSINESS
CONTINUITY PLAN
FOR
QUEENSLAND HEALTH
CENTRAL STERILIZING
DEPARTMENT
EXAMPLE HOSPITAL
TITLE
This plan shall be titled and known as the:
“BUSINESS CONTINUITY PLAN FOR QUEENSLAND HEALTH
CENTRAL STERILIZING DEPARTMENT, EXAMPLE HOSPITAL”
AUTHORISATION
The Plan provides the mechanism for restoring core essential services should an
unplanned interruption occur causing a loss of capacity in Central Sterilizing
Departments. The Plan can also provide guidance in preparing for a planned closure
of all or part of the Central Sterilizing Departments capacity.
This plan only applies to Queensland Health central Sterilizing Departments.
APPROVED BY:
-----------------------------------------------DIRECTOR NAME
Executive Director – Director of Medical Services, EXAMPLE Hospital
EXAMPLE Hospital and Health Service
Date:
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Table of Contents
Abbreviations ..............................................................................................................................4
Instructions..................................................................................................................................4
Authority and Planning Responsibility.....................................................................................5
1. Introduction - Plan Overview .................................................................................................6
Purpose………… ......................................................................................................................6
Scope……………......................................................................................................................6
Framework………………. .........................................................................................................6
Rationale………… ....................................................................................................................6
2. Pre-Issue Planning – Essential Functions, Activities and Minimum Resources..............7
Essential Functions...................................................................................................................1
Table 1 – Identification of Essential Business Functions .........................................................7
Table 2 – Business Impact Analysis .........................................................................................9
Table 2a – Impact Ratings........................................................................................................1
Minimum Resource Requirements .........................................................................................10
Table 3 – Essential Equipment per function list.....................................................................10
Table 4 – Minimum Staffing Requirements ............................................................................12
Management of absenteeism .................................................................................................13
Table 5 – Staff Category Ratings............................................................................................13
3. Continuity Plan......................................................................................................................14
Table 6 - Determining Responsibilities and Operational Activities .........................................14
Operational Checklist..............................................................................................................15
Activation…………… ..............................................................................................................15
Service Agreements / Memorandums of Understanding........................................................15
Alternative Work Arrangements..............................................................................................15
Table 7: Alternative Facilities..................................................................................................16
Additional Assistance..............................................................................................................17
Returning to Normal Operational Mode..................................................................................17
4. Maintenance and Testing of Plan ........................................................................................18
Maintenance of Plan ...............................................................................................................18
Testing of Plan ........................................................................................................................18
5. Appendices............................................................................................................................20
Appendix 1a – Activity Summary: flow chart ..........................................................................20
Appendix 1b – Activities to be Undertaken.............................................................................21
Appendix 1c – Operational Checklist......................................................................................22
Appendix 1d – Business Impact Assessment:........................................................................23
Appendix 2 – Staff Contact List, Category Rating & Special Skills ........................................24
Appendix 3a – Reporting Template ........................................................................................25
Appendix 3b – TRANSIT Log .................................................................................................26
Appendix 4 – Essential Contact Log.......................................................................................26
Appendix 5 - Communication Guidance .................................................................................29
Appendix 6a – Service Agreement Answers about Your Facility ...........................................30
Appendix 6b – Service Agreement Questions about other Facilities .....................................31
Appendix 7 – Testing of plan ..................................................................................................32
Appendix 8 – Service Agreement / Memorandum of Understanding with ….. .......................33
Appendix 9 – Service Agreement / Memorandum of Understanding with ….. .......................33
Appendix 10 – Service Agreement / Memorandum of Understanding with ….. .....................33
6. Resources..............................................................................................................................34
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Abbreviations
BCP
BIA
CDB
CHRISP
CHO
CSD
CEO
DON
DTPM
FTE
HPID
HHS
HSPL
MI
NUM
SA
SOP
SUO
Business Continuity Plan
Business Impact Analysis
Communicable Diseases Branch
Centre for Healthcare Related Infection Surveillance and
Prevention
Chief Health Officer
Central Sterilizing Department
Chief Executive Officer (of HHS)
Directors of Nursing
Desktop Procedure Manual
Full Time Equivalent
Health Planning and Infrastructure Division
Hospital and Health Service
Health Services Purchasing and logistics
Medical Industry
Nurse Unit Manager
Service Agreement
Standard Operating Procedures
Single Use Only
Instructions
Yellow text boxes & highlights in this example are guides only.
Grey shaded text in the electronic templates are form fields to fill in with your own
details as required (these will not print out shaded).
All tables are filled out with sample information from a trial site as an example only.
Any tables with some information filled out in the templates are also example
information only as a guide for completion.
You should pay careful attention to ensuring you complete all tables with
requirements specific to your facility and Hospital & Health Service.
This example may not be complete and is intended as an example only.
The CSD BCP planning template is where it is intended for full information to be
completed for all BCP requirements.
The CSD BCP functional template should have information transferred across from
the “planning” template for ease of use if a disruption should occur.
Any names used in examples are for example purposes only and any correlation to
actual Queensland Health staff or other people is purely coincidental.
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Authority and Planning Responsibility
The development, implementation and revision of this Plan are the responsibility of
the Hospital & Health Service Chief Executive Officer (CEO) or nominated delegate.
Amendments to this plan need to undertake a formal approval process through the
CEO or delegate.
To ensure accessibility to the Business Continuity Plan (BCP), it is required to be
saved electronically on a network drive accessible by Central Sterilizing Department
(CSD) Nurse Unit Managers (NUM) and Operating Theatre, saved electronically as a
back up on an external hard drive or similar as well as printed hard copies in
essential areas as deemed necessary by the CEO or delegate.
Amendment List
Amendment
Amendment
Number
Date
2.0
13/1/2012
Sections Amended
Amended By
Final Example document to
assist with completing the
template
CHRISP
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1. Introduction - Plan Overview
Purpose
The purpose of this BCP is to detail the key people/positions and the responses and
actions needed to enable Queensland Health (QH) Central Sterilizing Departments
(CSD’s) to continue essential functions in the event of a service disruption.
All CSD staff should familiarise themselves with this plan and the role(s) they may be
expected to assume during a service disruption.
Scope
BCP’s should be reasonable, practical and achievable. This BCP focuses on
consequences from disruption to CSD. It is not concerned with the likelihood or
cause of occurrence, as they are not elements of the BCP. This BCP makes no
attempt to cover any situation other than those that impact directly on CSD and their
ability to meet the core objective of providing the necessary services for reprocessing
of re-usable surgical instruments and equipment.
This BCP is intended only for use by CSD and facilities that rely on CSD for
reprocessing of instruments & equipment.
Framework
Queensland Health operates under an Emergency Preparedness and Continuity
Management Policy and Framework. This BCP is recommended to be adopted as a
sub-plan of the Business Continuity Plan of the Individual Hospital & Health Services
and facilities requiring CSD and to complement the overall Queensland Health
Emergency Preparedness and Continuity Management Policy.
http://www.health.qld.gov.au/qhpolicy/docs/pol/qh-pol-315.pdf
Rationale
Implementing this BCP is a reactive process where the careful assessment of the
type and severity of the service disruption will determine the necessary actions. It is
not possible or practicable to develop detailed recovery plans for every possible
incident type. This recovery plan focuses on a systemic approach to business
continuity while seeking to minimise confusion over roles and responsibilities within
QH CSD.
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2. Pre-Issue Planning – Essential Functions, Activities and Minimum Resources
Essential Functions
As each Hospital & Health Service & facility have different capabilities, urgency for continuation of services, and opportunities for contingencies, it is
impossible to develop a standard Essential Business Function table. A table is provided below as a guideline. The table lists, as an example, the essential
functions specific to a facility, skills & equipment required, maximum acceptable outage (how long can the business continue without this service), priority of
getting it back on-line & other relevant comments
Table 1 – Identification of Essential Business Functions
Essential Business Skills Required
Equipment Required
*Maximum
Function or
Acceptable Outage
Process
E.g. Reprocessing Working knowledge Manual washing chemicals
2 days
of reusable
of sterilizing
surgical
equipment.
Mechanical washing chemicals
2 days
instruments and
equipment.
Mechanical washers
1 day
(Standard Sets.
These are mostly
Ultrasonic
2-4 days
basic items with
several in stock
Drying cabinets - instruments
2 day
like Major trays
and also include
Drying cabinets – anaesthetic
1 day
items for
Packaging materials
1 day
Community
services.)
Heat sealer
1 day
Pre Vac sterilisers
Sterrad Sterilisers for heat
sensitive items
*Priority
2
1
Comments
Hand washing is backup if
washers go down; may
need more staff
Can fall back to manual but
more staff needed
1
Can fall back to manual
but more staff needed
3
Only have one; main impact
is orthopaedics.
2
Have x 3 of this type
1
Only have one of this
1
Alternatives not always
available
2
Have two tho’ one is
smaller
1hr - 2 days
1
1 day
1
Depends on both how
many are working on the
day and our workload on
the day
Have x2 but even that may
not be enough on the day
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Essential Business
Function or
Process
E.g. Reprocessing
of reusable
surgical
instruments and
equipment.
(Specialist
Instrumentation
defined as all other
instrumentation
whether trays or
single items of
small inventory and
including items that
may be needed in
emergencies)
Skills Required
Equipment Required
Working knowledge
of sterilizing
equipment.
Knowledge of
cleaning of
complex
instruments
Manual washing chemicals
1 day
1
Impacts on Ortho; is
backup if washers go down
Mechanical washing chemicals
2 days
1
Can fall back to manual but
more staff needed
Mechanical washers
1 day
1
Can fall back to manual
but more staff needed
Ultrasonic
2 days
1
Impacts on Ortho.
2 days if partial
1 day if none
1 day
2
1
1
Have x 3
Packaging materials including
tapes
1 day
1
Heat sealer
1 day
2
May go up a size in paper;
not down; can’t seal without
tape
Have two tho’ one is
smaller
1hr – if none
2 days – if >50%
1
1 day
1
Drying cabinets - instruments
Drying cabinets - anaesthetic
Pre Vac sterilisers
Sterrad Sterilisers for heat
sensitive items like
bronchoscopes
*Maximum
Acceptable Outage
*Priority
Comments
Only have one
Depends on both how
many are working on the
day and our workload on
the day
Have x2 but even that may
not be enough on the day
Maximum Acceptable Outage is taken from table 2 (Business Impact Analysis) and used to determine above Priorities.
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Table 2 – Business Impact Analysis
This considers the Essential Business Functions required to continue CSD services and rate the impact over the period of time using Table 2a – Impact
Ratings table below. E.g. if an Essential function was to be out between 2-7 days, would it be considered 4-Major, or 5-Catastrophic…. & is the maximum
acceptable outage when the rating gets to moderate, or major? Utilise Appendix 1: Business Impact Analysis questionnaire for further guidance.
Note: Depending on the combination of variables, the NUM CSD may alter the Impact Rating and the time at which it occurs.
e.g Reprocessing of reusable
surgical instruments and
equipment. (standard sets)
1
2
3
-
4
4
4
e.g. Reprocessing of reusable
surgical instruments and
equipment. (specialist
procedures)
2
2
4
4
5
> 1 month
2 - 4 Weeks
1 - 2 Weeks
2 - 7 Days
1 Day
Essential Business
Function
1 -4 Hours
Impacts
(Rate 1 to 5)
5
Highest Impact
(Provide a
description of the
highest rated
impact)
Depending whether
outage is partial or
total, use of other
facilities would be
needed.
Depending whether
outage is partial or
total, use of other
facilities would be
needed.
MAO
(Maximum
Acceptable
Outage)
2 Days; may be
less depending
on scenario as in
Table 1.
1 Days/12 hours?
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Internal short term
work arounds (to
consider if always
available to reduce
impact rating)
*Implementation of a 24
hr service that we don’t
now have.
*Additional staff to hand
wash.
*Borrow Oral Health
bench top sterilisers.
*Implementation of a 24
hr service that we don’t
now have.
*Additional staff to
hand wash..
Comments
Many variables need
to be considered e.g.
if no sterilisers were
available, we would
go to contingency by
4 hours. If the
problem were with
washers, the impact
would not be felt until
more time lapsed.
Many variables need
to be considered e.g.
if no sterilisers were
available, we would
go to contingency by
4 hours. If the
problem were with
washers, the impact
would not be felt until
more time lapsed.
9
Table 2a – Impact Ratings
Rating
1
2
3
4
5
Category
Insignificant
Minor
Moderate
Major
Catastrophic
You will need to define what these categories mean in collaboration with
NUM Perioprative in relation to Surgical Services
Description
No measurable operational impact to the business.
Minor degradation of operations or service delivery.
Substantial degradation of operations or service delivery.
Significant degradation of operations or service delivery.
Widespread and total degradation of operations or service delivery.
Minimum Resource Requirements
The minimum resource requirements for each task include equipment, consumable and human resources. When considering human resources, it may be advisable
to not only consider the number of staff required, but also the category of the staff required. (from Table 5).
Table 3 – Essential Equipment per function list
Essential Function or
Process
Rinse/Wash
Ultrasonic
Equipment Required
Double Sinks
Validated Washer
Disinfectors including
one with Anaesthetic
capability and all with
Printouts
Leak Tester
Bench top type
Infrastructure (power,
water, etc.)
Reverse Osmosis Water
Town water
Power
Air gun
Water gun
Air conditioning 18-22C
Write Up area
Other (consumables, etc.)
Town water
Power
Air conditioning 18-22
Chemicals
Test equipment
Personal protective equipment
Lint free cloths
Chemicals
Soil removal tests
Blue food dye
Cleaning brushes
Clean cotton drapes
Linen skip
Waste bin
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Dry
Instruments Drying
cabinets including one
for Anaesthetic’s
Trolleys
Power
Clean cotton drapes or towels
Wrap/Pack
Wrapping tables,
preferably height
adjustable
Heat sealer
Magnifying Light
Electrosurgical
insulation tester
Computer and printer
Air conditioning 18-22C
Wrapper, sterilisation synthetic sizes 45 x 45 to 137 x 137
Tape seal sterilisation with chemical indicator (steam)
Tape seal sterilisation with chemical indicator (Sterrad)
Manual tracking system labels (steam)
Manual tracking system labels (Sterrad)
Tip protectors
White textile (cotton) tape 6mm
Permanent marking pens as per AS4187
Autoclavable tray liners
Plastic bags
Oxygen tubing
Plastic sleeves for tray checklists
Sterilize
Water + power (steam)
Log sheets
Transit Forms
Cool down
Loading trolleys
Write up area
May need closed
trolleys for transport
externally.
Trolleys
Sterile Storage
Dedicated area as per AS4187
Air conditioning 18-22C
Loan Sets
As for Wrap / Pack
Write up Area
As for Wrap / Pack
Air conditioning 18-22C
Stationery
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Table 4 – Minimum Staffing Requirements
All facilities have differing standard operating hours & staffing needs. The Current Resource figures below represent the normal numbers of staff rostered
in CSD at trial hospital. The Resource Requirements below helps to guide the numbers of additional staff that may be needed. The resource
requirements may vary significantly depending on the amount of service capacity remaining and whether outsourcing to multiple sites and / or
implementing a temporary night duty shift.
Current Resource Level
Essential Business Functions (available to complete
key business process)
AM
Reprocessing of reusable
surgical instruments and
equipment standard and
specialist)
7
PM
6
W’end
3
Additional Resource Requirements.
Minimum additional levels required to complete key
business processes (we need to consider that we may
require additional resources in some instances. e.g if
functions being performed off-site or alternate location
within the facility or if a Night Duty shift needs to be
implemented where it is not normally worked.)
<1
hour
0
1-4
hours
+1
1 Day
2 to 7
Days
+2
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+2
1-2
Weeks
+2
2-4
Weeks
+2
Manual Alternate
Workarounds
(Yes/ No)
>1
Month
+2
Yes (single use
only; see table 1)
12
Management of absenteeism
While minimum staffing levels are factored into the Business Impact Analysis and
are listed in the Minimum Staffing Requirement section, management of
absenteeism becomes an issue in itself in the context of prolonged leave or
absence.
Proper management of absenteeism will allow the Hospital & Health Services to
continue to deliver essential services even in the face of increased and prolong
absences of staff. To help determine appropriate placement of staff, the following
categories have been developed.
Consideration also needs to be given to the fact that additional staff on top of normal
operating levels may well be required upon activation of the BCP due to the break of
the usual workflow making it difficult for staff to move between stations and cover
multiple areas.
Table 5 – Staff Category Ratings
This table is internal use only, please amend definitions to suit as required.
Staff
Category
Category 1
(NUM CSD)
Category 2
(2nd in charge
CSD)
Category 3
(Normal Staff)
Category 4
(Other facility
staff with
transferable
skills)
Category 5
(As with
Category 4 that
may be
released to
alternate sites)
Definition
Personnel who perform an essential function that must be
maintained within Sterilizing Services.
Personnel who can be used as secondary support for Category 1
staff due to multi skilling / cross training.
Personnel who perform an essential function and where such a
function can continue to be effectively provided from a remote
location e.g. another facility with which a MOU may be in place
and activated.
Personnel whose work cannot be done from another facility but
can be deferred for a period of time e.g. minimum requirements
can be achieved by 2-3 days per fortnight. May be resource
shared on limited basis within the facility.
Personnel with deferred functions – available for redeployment
from within the facility / Health Hospital Service.
Refer to Appendix 2 – Staff Contact List, Category Rating & Special Skills
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3. Continuity Plan
Table 6 - Determining Responsibilities and Operational Activities
The following table outlines the key functional areas and who has responsibility for those areas.
Functional Areas
Position
Alternate or Standby
Activation of BCP
DON Your Hospital
*NUM – CSD
*Nursing Director –
Surgical
Key
Reports to
Responsibility/Activity
Initiate contact with key ED Your Hospital
stakeholders to
determine level of
activation (appendix 5
& 3)
Make contact with key
DON Your Hospital
stakeholders from
Appendix 5 & proceed
as directed in Appendix
3 to facilitate smooth
activation of CSD BCP
Contact key BCP
Nurse Unit Manager,
Central Sterilizing
Department Your
Hospital
*NUM Operating
Theatre
*Nursing Director –
Surgical
*Engineering Manager
*Hospital Co-ordinator
Contact Central
Sterilizing Department
Staff
Nurse Unit Manager,
Central Sterilizing
Department
Hospital Coordinator
Contact staff to advise
of alternative work
arrangements
DON Your Hospital
Return to normal
operation
Nurse Unit Manager,
Central Sterilizing
Department
*Engineering Manager;
*DON local facility;
*Sterilizing Program
Manager CHRISP
*CSD Shift Supervisor
(only if < 4 hours)
Assess functionality &
capability of CSD as
being able to perform
essential functions &
notify key stakeholders
(appendix 3) of return
to normal.
ED Your Hospital
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Operational Checklist
The following resources have been developed to ensure all required tasks are
documented so that the essential functions of CSD BCP are maintained:
y Appendix 1a – BCP activation flow chart
y Appendix 1b – Activities to be Undertaken
y Appendix 1c – Operational Checklist
Activation
The decision to activate this plan independently of the BCP of the Local facility is the
responsibility of the DON. Once this decision has been made, the NUM CSD will
notify the key stakeholders in Appendix 4 and utilise Appendix 5 – Communication
Guidance in contacting the relevant stakeholders.
Activation of the BCP of the local facility may not always necessitate the activation of
the CSD BCP.
Activation of the local facility BCP may in fact negate the CSD BCP, or alternatively
rely on parts or all of the CSD BCP.
Service Agreements / Memorandums of Understanding
As outsourcing of CSD is anticipated to be a major part of the continuity of CSD, a
Service Agreement (SA) or Memorandum of Understanding (MOU) between parties
may be needed. For assistance in establishing a MOU or SA with other facilities,
contact your local Contract Hub for assistance. Refer to QHEPS site:
http://qheps.health.qld.gov.au/sspd/supply/contracts_about_hubs.htm
If a MOU or SA is created, a brief summary of each should be recorded as an
Appendix. A list of some suggested questions to ask when setting up such
agreements is located in appendix 6 Service Agreement questionnaire.
Alternative Work Arrangements
There are a number of options to consider when alternative work arrangements and
the relocation of essential functions are required. It is the responsibility of the NUM
CSDs, to determine the best option at the time of disruption. The options available
may include but are not limited to:
y Relocating to another section within same building; (is there another room
that may be utilised as: initial wash/remove gross debris, clean area for
wrap/pack, sterile storage (unutilised theatre), Oral Health Bench Top
Sterilizers)
y Relocating to alternate facilities as arranged in the MOU or SA (if any) &
outlined in Table 7.
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Table 7: Alternative Facilities
(examples only)
Capacity to
accept % of
normal load
(full service)
Ability to reprocess
complex sets: (list
specialities)
Alternate
Location
or Facility
Tasks able to be undertaken
at this location
Private
Facility 1
Cleaning and sterilizing
standard and some special
instruments
%
General and
Orthopaedics; may
need to send our staff
Private
Facility 2
Cleaning and sterilizing
standard and some special
instruments
%
General and
Orthopaedics; may
need to send our staff
All tasks
%
All specialties with our
staff
All tasks
%
All specialties with our
staff
All tasks
%
All specialties with our
staff
All tasks
%
All specialties with our
staff
Cleaning and sterilising
standard instruments
%
Consider borrowing bench top
sterilisers and having them
brought to Redcliffe CSD
%
Standard and some
special items with our
staff; Dental staff may
need to be arranged to
support us.
Our staff working here
All tasks
%
QH facility
within
Hospital &
Health
Service 1
QH facility
within
Hospital &
Health
Service 2
QH facility
within
Hospital &
Health
Service 3
QH facility
outside
Hospital &
Health
Service 1
Oral
Health
dedicated
CSD
Oral
Health
Clinics
Other
(dept. of
Defence?)
All specialties with our
staff
Please refer to the MOU or SA (if any) for Hours of Operation, and Staffing
Requirements for each facility above.
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Additional Assistance
Appendix 4 outlines a list of key stakeholders who will provide additional assistance to
influence CSD BCP.
A key requirement for additional assistance may be transport providers. Supply Services
logistics managers may be of assistance, as well as engaging external freight
management/transportation companies.
We will need to ensure that this complies with AS/NZS 4187:2003 sections 2.3, 2.4, 9.2.1 &
9.4 as well as referring to Easi-Sterilise Standard Operating Procedures 1.2 & 4.3
http://www.chrispqld.com/easi_sterilise/easi-sterilise.html.
When making arrangements to out-source, consider logistical factors like loading dock
heights relative to the trucks, access to these and / or to the other facility. Ask questions like
“Do Security need to open gates?”
Returning to Normal Operational Mode
The NUM CSD/Nursing Director – Surgical Services will keep all team members
updated and advise when return to normal operating mode.
Remedial action will be completed as required to integrate work completed during the
continuity operating mode.
The NUM CSD/Nursing Director – Surgical Services shall notify all clients\other
departments of the return to normal business operations.
The Nursing Director – Surgical Services is responsible for timely debriefing sessions
with staff. Lessons learned should be used to update BCP.
Appendix 1c – Operational Checklist includes checks for returning to normal operational mode.
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4. Maintenance and Testing of Plan
Maintenance of Plan
All files associated with this plan can be found in:
Electronic:
Local network drive (accessible by all key stakeholders)
USB portable drive (kept in accessible location for all key stakeholders)
Hard Copy: Education Room CSD
NUM Office CSD
Hospital Co-ordinator Office
Amend Hard Copy & Electronic copy locations to suit your specific needs &
governance structure
The CHRISP base templates and example will be saved at:
http://www.health.qld.gov.au/chrisp/sterilizing/sterile_support.asp
When the plan is tested and/or revised or any of the tables, appendices and/or
content of this BCP is updated, it is important to save a copy of these files not only to
the designated directory but also save them to the external source and reprint/amend the hard copy.
If minor amendments only are required, there may be no need to re-print the hard
copy of the document, just simply cross out & change as required, initial & date the
changes.
Testing of Plan
Responsibility for testing the plan rests with both the NUM CSD and the Nursing
Director – Surgical Services.
Testing of the plan does not require full physical activation, but a “table top
activation” consisting primarily of the communication requirements such as
contacting Management, Engineering, NUMs of other facilities, Transport providers,
and CSD staff to ensure readiness without actually actioning the BCP.
The testing of the plan should not only simulate a loss of capacity in functionality of
CSD hardware resources, but also with a loss of people in critical positions. This will
confirm the BCP is functional / usable for all staff that may be required to use it.
Start the conversation for testing the plan with the following:
“This is a theoretical simulation of the EXAMPLE Hospital CSD BCP”
The BCP Plan should be tested at the following timelines and recorded in
Appendix 7 – Testing of Plan:
o following initial completion of the plan;
o following any major revisions of the plan; and
o bi-annually.
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
5. Appendices
Appendix 1a – Activity Summary: flow chart
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Appendix 1b – Activities to be Undertaken
1. Identification of Fault/Disruption (Document the entire process as it unfolds to
make writing a report at the end easier & ensure all information is captured to
be able to review the BCP, SA’s & MOU’s)
a. Notify Engineering to ascertain cause & determine possible length of
disruption
b. Notify Nursing Director – Surgical & Nurse Unit Manager – Operating
Theatre. (keep notifications current as more information comes to hand
in steps below)
c. Notify CHRISP (keep notifications current as more information comes
to hand in steps below)
2. Determine if disruption will exceed maximum acceptable outage as
determined in Tables 1 & 6
3. Determine if Activation of SA’s/MOU’s is required & to what extent (is it a
washer only that is out of service, sterilizer only etc. & what % of capacity is
required to be sent off-site);
a. Yes – contact CSD NUM’s of the facilities you have set SA/MOU’s with
b. Yes – Contact your staff to inform of alternative work arrangements
c. Yes – Contact other service providers for transportation needs
d. No – Inform key stakeholders (Nursing Director – Surgical, Nurse Unit
Manager – Operating Theatre, CHRISP, etc.) as to what capacity the
CSD can operate at, and when CSD is predicted to be back to 100%
functionality.
4. Monitor the effectiveness of SA/MOU’s & other works being undertaken to
provide continuity of essential functions.
5. Once CSD is operational to resume all essential functions, cease SA/MOU’s &
inform all key stakeholders
a. Report on the event using appendix 4 to DON & CHRISP outlining:
i. Issue that caused disruption
ii. Barriers to rectifying
iii. Barriers to continuity (e.g. any issues activating SA/MOU)
iv. Acknowledge what worked well
v. Time line of events
vi. Conclusion & any recommendations for improvement.
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Appendix 1c – Operational Checklist
Action
1. Complete & maintain (ongoing outside/prior to
activation of the plan)
Tables 1, 2, 3, 4, 6 & 7
Appendix 3 – Staff contact, Category Rating &
Special Skills
Appendix 5 – Essential Contact List
2. Contact (upon activation)
Appendix 5 – Essential Contact List
Appendix 2 – Staff Contact, Category Rating &
Special Skills
Reason
Done
To keep plan current
To keep plan current
To keep plan current
To determine fault &
begin continuity
measures
To respond to
required activation
needs (such as
alternative work
arrangements)
3. Recording of Events (During activation of BCP)
Document which Service Agreements are being
To assist with
utilised & what portion of work is being carried out tracking of
at each facility.
instruments,
accountability of
work
Maintain a log of inventory out & in, including
To assist with
documentation of processes undertaken at
tracking of
alternate facilities to ensure compliance with
instruments,
standards. Appendix 4a – Tracking Log
accountability of
work
Document agreements/contracts with other
To assist with
external providers such as transport/freight
tracking &
companies
accountability of
transportation
Document steps taken to rectify the issue within
For future reporting
CSD
needs
4. Resume Essential Functions
Inform all Key Stakeholders & Staff that were
Alleviate workload of
contacted in step 2 (from Appendix 2 & 5) and
assisting CSD,
cease all SA/MOU with alternate facilities and
return to normal and
additional assistance with external stakeholders
best practice
once CSD is functional to perform essential
processes.
functions.
Report on the entire process from initial issue
To be able to
through activation of BCP to resumption of
evaluate and
essential services. (Include comments/reports
possible
from facilities assisting). The severity of the issue improvement on the
will determine the detail of the report.
process to share
Reports to go up the chain within the facility & to
with all Queensland
CHRISP using template on appendix 4.
Health CSD
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Appendix 1d – Business Impact Assessment:
Questions to Consider in Making Decisions about Activating the Plan
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Appendix 2 – Staff Contact List, Category Rating & Special Skills
Contact made via NUM CSD or delegate. Contact details kept with within TRENDCARE.
Name
Category Rating (as
per Table 6a)
1
1
1
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
5
Special Skills
Nurse Manager Sterilising Services
Loan Set Coordinator Orthopaedics
NUM Operating Theatre
RN and CSD Technician
RN CSD Technician
Current CSD Technician
Current CSD Technician
Current CSD Technician
Current CSD Technician
Current CSD Technician
Current CSD Technician
Current CSD Technician
Current CSD Technician
Current CSD Technician
Current CSD Technician
Current CSD Technician
Current CSD Technician
Current CSD Technician
Current CSD Technician
CSD Technician (casual)
CSD Technician (now in OT)
CSD Technician (now in Clinics)
CSD RN (now in OT)
CSD Technician (now PFT in ICU)
Manual cleaning
Manual cleaning
Manual cleaning
Manual cleaning
+ Wrap
+ Wrap
+ Wrap
+ Wrap
(casual)
(casual)
(casual)
(casual)
Manual cleaning + Wrap (PPT Mat’y; ex – CSD)
Perioperative Educator
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Appendix 3a – Reporting Template
For Impacts 2 or above as per Table 2 above
Insert Date
Insert Facility Name
Date:
Location:
Brief description of issue. E.g. loss of steam to sterilizers, Power failure.
Issue:
Contact / Notification:
Services Utilised:
Who:
Reason: e.g. to activate BCP, to notify of issue, to
request assistance/ activate service agreement
Who:
Service provided: e.g. equipment transport, 30% sterilization requirements,
50% wash, wrap & pack
Rectification Steps: (include any barriers encountered)
Step: e.g. Engineering to look at steam supply
Response:
CSD back functional:
dd/mm/yyyy
Service Impact/
Additional Comments:
(if not enough space below, please attach additional sheet/s with comments)
Date full service resumed:
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How Long:
date started – date
finished
dd/mm/yy - dd/mm/yy
Rectification Date:
dd/mm/yyyy
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Appendix 3b – TRANSIT Log
Instrument Sets or
Single items Sent
Eye instrument set
Sent To
(facility) with
(transport
option)
Neighbouring
facility
For
Process
(e.g.
washing,
sterilizing
etc)
Sterilizing
Date /
Time sent
& initial
29/5/12
11:15 BS
Received
by
Joh
Date /
time
Goods
Sent &
initial
Date / time
Goods
Received &
initial
29/5/12
13:35 JG
29/5/12
13:55 BS
Copy of
process record
(if applicable)
attached to
relevant log &
initial of staff
Appendix 4 – Essential Contact Log
Some standard contacts have been placed. By grouping them in specific areas, it will be easier to follow & keep track of who has been contacted & prioritise
order of contact (1 high, 5 low and may depend on level of disruption/activation).
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Area /
Internal /
External
Your
Hospital
Name
Position
Department/Company Phone
Number
ND-Surgical
NUM
OT co-ordinator
A/Deputy Engineer
Manager BEMS
Hospital Coordinator
DON
Deputy Director
Medical Services
Director of
Corporate Services
Infection Control
CNC
NUM
NUM
NUM
NUM
Nursing Admin
OT
OT
Engineering
Engineering
Nursing Admin
Contact Advice
Priority &
Support
1
1
1
1
1
2
Nursing Admin
Medical Admin
2
2
Corporate Services
3
Nursing
3
Emergency
ICU
DPU
LW
3
3
3
3
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Notification
Only
27
Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Area /
Internal /
External
Name
Position
Corporate
Office
Rosemary
Steinhardt
Sterilizing Program
Manager
Other Qld
Health
contacts
Department/Company Phone
Number
CEO
CHRISP
NUM CSD
Your Hospital & Health
Service / HHS
Other facilities
DON
Other facilities
332 89767 /
0427672713
Contact Advice
Priority &
Support
Notification
Only
2-3
Via Executive
4
See Appendix
6b
See Appendix
6b
2-3
3
External
Contacts
SOA contracted
transport/delivery
provider
Medical Industry
NUM CSD
DON
Transportation
contractors
Private facilities with
SA/MOU
Private facilities with
SA/MOU
Via Corporate
Services
2
Via Corporate
Services
See
SA/MOUs
See
SA/MOUs
Via Corporate
Services
2
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2
2-3
2
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Appendix 5 - Communication Guidance
Clear, concise and consistent message
Clearly define target audience – one message does not fit all.
•
•
•
•
•
•
•
Good Morning/Afternoon, this is Insert Name from Insert Facility &
department.
I am calling to inform you that the Insert facility & department has experienced a
partial/total loss of reprocessing capacity in the form of (Sterilizing, washing,
wrapping & packing etc….) .
We will be initiating our BCP and (if applicable) the Service Agreement
(SA)/Memorandum of Understanding (MOU) we have with you. Can you please
advise of any change to your capacity to undertake works in (Sterilizing,
washing, wrapping & packing etc….) on our behalf.
We have urgent requirements such as e.g. Fast Tracked Sets that will be top
priority and with your approval will be sent your way.
We have/will arrange for transportation of these items with name of transport
company/contractor and their direct contact is insert name of contact details
for transport company/contractor should you have any issues at your end.
We will keep open communication channels throughout the process to ensure we
are providing you with the support you need while assisting us as agreed in the
SA/MOU. We will let you know when we will be returning to business as usual.
Thank you for your support.
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Appendix 6a – Service Agreement Answers about Your Facility
Question?
What are normal operational hours?
What capacity is available within this
time?
What extended hours are possible?
What capacity is available in the
extended time?
What are your Sterilizers validated
for? (Including wrap type/procedure)
What specialist instruments are you
able to reprocess?
What is maximum height of your
loading dock?
Does the dock have ramps?
How can we overcome security &
achieve easy access at the dock?
Applicable Comments / Response
Y/N
Mon – Fri.
0700 – 2300
Sat/Sun/PH 0700 – 1730
Cleaning; Sterilization by
steam and Sterrad 100S.
Night duty by negotiation
Maximum 1 staff member
One Step; laminates
packaging. Multiple steam
i l di Gynae
S
i l
Bronchoscopes/
Scopes / Orthopaedics /
Urology (Sterrads)
Yes
Non secure dock
This form can be used as a quick response for other facilities who may require your
assistance.
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Appendix 6b – Service Agreement Questions about other Facilities
Question?
Applicable
Y/N
Comments / Response
What are normal operational hours?
What capacity is available within this
time?
What extended hours are possible?
What capacity is available in the
extended time?
What are your Sterilizers validated
for? (Including wrap type/procedure)
What specialist instruments are you
able to reprocess?
What is maximum height of your
loading dock?
Does the dock have ramps?
How can we overcome security &
achieve easy access at the dock?
This form would be completed and available as a resource for each facility with which
you may create a MOU.
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Appendix 7 – Testing of plan
The Plan will be tested biannually at a minimum. This does not require physical shut down of the CSD
& reprocessing at other facilities, but more a theoretical “desktop” exercise. This Exercise should
consist of contacting key stakeholders to check their preparedness to respond to a situation (Facilities
with whom we have a SA/MOU to take on our reprocessing, our staff, Medical industry, Engineering,
Supply Services, CHRISP). The results of this, especially with checking other facilities preparedness &
current capacity will allow us to update this plan & service agreements accordingly.
Test Date
15/3/2012
Type of Test
Desktop
exercise
Scenario
75%
Sterilizers ofline. NUM
CSD on leave
Staff Participating
CN CSD, RN CSD,
etc.
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Convenor
ND Surgical
Services
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
Additional Appendices to include any & all service agreements you create with other facilities
and external sources to provide contingency in the event of a loss of reprocessing capacity.
Appendix 8 – Service Agreement / Memorandum of Understanding with …..
Appendix 9 – Service Agreement / Memorandum of Understanding with …..
Appendix 10 – Service Agreement / Memorandum of Understanding with …..
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Appendices for Business Continuity Plan for Queensland Health Sterilizing Services
6. Resources
Resources available to support effective business continuity management,
completion of this template and activation of this BCP include, but are not limited to:
y
y
Link to local BCP
Queensland Health - Guidance Document - Emergency Preparedness &
Continuity Management
http://www.health.qld.gov.au/qhpolicy/docs/pol/qh-pol-315.pdf
y
EMERGENCY PREPAREDNESS, DISASTER MANAGEMENT AND BUSINESS
CONTINUITY
SELF
ASSESSMENT
CHECKLIST
http://qheps.health.qld.gov.au/audit/OE_Stream/emergprepardselfass.pdf and
other documents listed therein on page 2
y
CHRISP
Easi-Sterilise
Standard
Operating
Procedures.
http://www.chrispqld.com/easi_sterilise/easi-sterilise.html
AS/NZS 5050:2010 Business continuity – Managing disruption-related risk
y
AS/NZS ISO 31000:2009 Risk management – Principles and guidelines
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