Unformatted Attachment Preview
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Running head: CONTINUITY OF OPERATIONS PLAN
Continuity of Operations Plan
Example
CONTINUITY OF OPERATIONS PLAN
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Continuity of Operations Plan for Wilmington Hospital
1.0
Executive Summary
A continuity operations plan is developed for Wilmington Hospital located in Wilmington City,
Delaware. The plan documents how the health facility will perform essential functions in the
case of an emergency event lasting for up to 30 days. The COOP plan identifies the essential
functions of the facility as well as supportive resources that may be affected in the case of an
emergency (Clark and Biddinger, 2013). A COOP team to handle management of activation,
relocation and reconstitution of key resources has also been developed as well as the flow of
information during such emergencies. A concept of operations framework is also provided to
guide the management team on how to conduct organizational functions during emergency
scenarios. Upon recognition of the diversity of risks and hazards that may occur, a criterion to
designate delegation of authority and ensure continuation of operations has also been developed
to maintain functionality of essential functions within the healthcare facility. The management
team of Wilmington Hospital upon approval from the department of health has also acquired
permission from two neighboring health facilities to act as alternative facilities where key
operations may be run from in case of emergency events.
2.0
Introduction
The continuity of operations plan is an important element of strategic management that ensures
that organizations are well prepared in case of disasters and other emergency events. The COOP
plan contains resources, action-plans, guidelines and procedures on how to manage events that
may disrupt normal operations. The focus of the COOP plan is usually the essential functions of
an organization whose disruption may result to gross harm, damage or even death (Clark and
Biddinger, 2013). An extensive risk and hazard analysis should be conducted to help organizations
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project possible steps of concerns as well as the impact on essential functions. Development of
such plans hence involve both internal and external organizational stakeholders including local
area emergency response teams who are most likely to offer help in such times. The COOP is to
be availed to all organizational personnel so that each member is aware of their responsibilities
and roles in the case of emergency events (Virginia Department of Emergency Management,
2010).
3.0
Purpose
The purpose of this healthcare Continuity of Operations Plan is to provide a framework upon which
essential functions may be restored effectively in the case of an emergency or related incidence.
This report provides the healthcare COOP program procedures which will cover the following
types of disruptions within the facility:
•
Failure to access the healthcare facility
•
Failure to provide healthcare services as a result of system or equipment breakdown
•
Failure to provide healthcare services due to a reduced number of employees
Procedures to counter the above disruptions within the specified recovery time are discussed as
well as the actions necessary to run essential functions of the facility for about 30 days. The
emergency department of the institution aims to ensure patient and employee safety as well as
safeguard all resources owned or utilized by the hospital. The COOP is therefore a mitigation
measure aimed at reducing the potential impacts and risks during unplanned events and
disruptions (Federal Emergency Management Agency, 2016).
4.0
Applicability and Scope
The plan’s course of action is applicable to all personnel and processes that are related to essential
functions. Any potential events or hazards that could cause disruption in the provision of services
CONTINUITY OF OPERATIONS PLAN
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or lower the performance of key functions within the facility are addressed. Only major events are
covered in this plan hence temporary or short-term disruptions are ignored.
This COOP plan is designed based on the guidelines provided by the City of Wilmington’s,
Delaware, basic plan.
Upon its verification by relevant authorities, the plan will be distributed to the management team
of the healthcare facility and a training plan may be scheduled at the jurisdiction of the chief
executive officer to enlighten the workforce on the same. The CEO will also see to it that the plan
is shared with the city’s emergency response department for recommendation and approval.
4.1
Essential functions
The emergency department identifies several healthcare services and supporting resources to be
essential in the facility. The COOP sets recovery time objectives that regards the reconstituion of
several key processes to normal operation (ASPR, 2015).
The essential functions plan is highly dependent with the type of services offered at the health
facility and as such may be varied to suit different operational environments. The essential
functions are listed in appendix A.
4.2
COOP team
The COOP team will be a team comprised of several employees and the management team who
will have adequate training on emergency cases (Morash, 2013). This team will be expected to
carry additional responsibilities and functions in the case of an emergency which are highlighted
in the plan below:
4.2.1 Head of emergency department
-
Will be the head of the COOP implementation process
CONTINUITY OF OPERATIONS PLAN
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Coordinates with the city of Wilmington’s emergency and response department with
regard to any assistance on restoration of essential functions
-
Will advise departmental heads on the various steps of actions to take in the case of
emergency
-
Will consult with the City’s emergency response team if need be.
-
Reports to the chief executive officer
4.2.2 COOP Coordinators
-
Each department of the healthcare facility will have a COOP coordinator
-
Will function to coordinate the COOP implementation in each department
-
Will play an important role in identification of essential functions that may be affected by
a particular disruption
-
Initiate recovery process of essential functions e.g. through relocation
-
Designates various responsibilities to other departmental employees with regard to the
COOP implementation
-
Will report to the head of the emergency department
4.2.3 Reconstitution managers
-
Will be based in every department
-
Main function will be to provide a time based plan of activities on how the department’s
essential functions will be resumed
-
Also ensures that the physical operational area is safe for continued operations and if not
sanction for a relocation
-
Reports to the departmental COOP coordinator
4.2.4 Departmental personnel
CONTINUITY OF OPERATIONS PLAN
5.0
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-
Expected to have adequate knowledge of the COOP implementation process
-
Be knowledgeable of individual roles and responsibilities in the case of emergency
-
Ensure that patients are well taken care of during the continuity environment
-
Reports to the departmental reconstitution manager
Risk assessment
The emergency department is to conduct an extensive analysis on possible risks and threats to
essential operations of the healthcare facility. The risk assessment process may be conducted in
conjunction with the city of Wilmington’s emergency response department for more conclusive
findings. Some of the pre-identified risks associated with the facility are tabulated below:
Hazard
Type
Frequency
Duration
Magnitude of risk
Communication breakdown Technological Moderate
Moderate
Moderate
IT system failure
Technological Moderate
Moderate
High
Tornado
Natural
Short
Moderate
Power loss
Technological Rare
Short
High
Moderate
Table 1
6.0
Continuity Elements
The facility’s healthcare management in collaboration with the department of health has set up a
succession order in the case individuals holding leadership or managerial position are incapacitated
to perform their roles effectively e.g. due to death and resignation.
Position
Successor 1
Successor 2
Chief executive Medical Director Chief nurse
officer
Successor 3
Successor 4
General manager Director
pharmacy
of
CONTINUITY OF OPERATIONS PLAN
Medical Director Chief Nurse
Chief Nurse
7
General
Director
Manager
pharmacy
General manager Director
pharmacy
of Patient
of Patient
service
manager
service Administrator
manager
Table 2
6.1
Continuity of operations
The board of the healthcare facility upon approval by the department of health has identified 2
healthcare institutions to transfer essential healthcare functions in the case of an emergency event.
Below is a description of the two facilities:
Alternative facility
Type of facility
Location
St. Francis Hospital
General hospital
701 N Clayton St, Wilmington, DE
19805
Nemours/Alfred I. duPont Hospital for Children
1600 Rockland Rd, Wilmington, DE
Hospital for Children
19803
Table 3
6.2
Delegation of authority
The emergency department upon approval from the board of directors provides a criterion for
delegation of authority in the case of an emergency event. The delegation of authority criterion
will be triggered in the event that the normal administrative protocol is disrupted e.g. due to death
of persons in a leadership position (Virginia Department of Emergency Management, 2010). The
said process will however be terminated once normalcy is resumed within the healthcare facility.
CONTINUITY OF OPERATIONS PLAN
Authority
Type
of Position
authority
8
Successors
Triggering conditions
holding
authority
Closure of the Emergency
healthcare
CEO
authority
Chairman of Board of Unsafe environment for
directors, members of both
facility
Board of directors
Administrative
CEO,
Chairman of Board of When
healthcare
authority
Medical
directors, members of holding
Director
Board
of
Chief nursing officer,
external
General
City
e.g.
leadership
authority
team
is
directors, unavailable
meeting with
leaders
and
workforce
Represent
facility when
patients
manager,
Administrator
health
officials and
emergency
response
team
Relocate
Emergency
CEO,
Chairman of Board of Unsafe environment for
essential
authority
Medical
directors, members of both
Director
Board of directors
operations
patients
workforce
and personnel
to alternative
facility
Table 4
7.0
Concept of operations
The concept of operations is a framework that will be used by the healthcare facility to implement
the COOP effectively. The framework also aims to describe in the simplest way possible how each
element of the COOP will be covered (Virginia Department of Emergency Management, 2010).
and
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The concept of operations for the healthcare facility will be presented in tabular form and will
focus on the degree of disruption and a decision matrix. Depending on the nature of emergency,
the implementation plan may be altered to cater for the needs of each department within the
healthcare facility (Morash, 2013).
Degree of Category
Potential impacts Decisions to be made
disruption/
on
essential
functions
Emergency
of
healthcare facility
4
Day-to-day
Normal
operations/
operations within
Normal
the facility
operation
No decision
Adequate number
of
employees
reports to duty
3
Alert
An
anticipated Departmental personnel inform the reconstitution
emergency
scenario
which
manager who assesses the level of emergency
but
is
not
detrimental
to
The manager may not necessarily inform the COOP
manager since no COOP implementation is
required.
essential
functions of the The reconstitution manager should however
mobilize appropriate personnel to manage the
facility
situation
The impacts of the
emergency
scenario
are
projected not to
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last more than 12
operational hours
2
Partial
An emergency or The emergency department within the facility alerts
COOP
disruptive
implementat
scenario
ion
incapacitates
the management team including the chief executive
that officer.
The COOP coordinator meets with the CEO and
essential
discusses the steps of actions before alerting other
functions of the
COOP team members.
healthcare facility
for at least 3 days. The reconstitution manager embarks on a process
recovery process aided by personnel within the
Vital
processes
department as per partial COOP implementation
and
systems
guidelines.
necessary
for
healthcare
delivery
are The reconstitution manager may mobilize resources
affected
and personnel from other departments and activate
succession orders upon approval by the COOP
coordinator.
Relocation of key processes and personnel to a
secondary location for atleast 3 days may also be
done for continuity of operations.
The implementation process should however not
exceed 14 days since the emergence of the
disruptive event.
1
Full
A real disruption The emergency department within the healthcare
implementat
that
ion
detrimental
impacts
essential
has facility alerts all heads of departments as well as the
senior management team.
on
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functions of the The COOP coordinator alerts all team members of
healthcare facility the situation and provides instructions for the full
for at least 7 days. implementation plan.
Key processes and Activities carried out are heavily dependent on the
personnel
affected
are nature of emergency and the affected departments.
hence
requiring
an
immediate
full
The implementation procedure may however
involve relocation of key processes and personnel
as well as activation of succession orders.
COOP
implantation
The CEO at this juncture requests assistance from
procedure
the city of Wilmington’s emergency response team
to work together with the local COOP team in
restoration of essential processes.
The COOP coordinator works closely with
departmental heads to utilize available resources
efficiently.
the COOP implementation process should ensure
that essential functions are restored for at least 14
days during the emergency.
Table 5
7.1
COOP alert and notification
The COOP alert and notification plan aims to develop a criteria or procedure regarding the flow
of information in the case of an emergency or a disruptive event (Clark and Biddinger, 2013).
The alert tree is based from the time a risk or threat to the facility’s essential functions is
identified at the primary level to when all stakeholders are informed and appropriate actions
taken.
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The healthcare facility has a notification system installed at each work station in every department
that allows information to be disseminated within the shortest time possible. The management has
also adopted an open-door policy where junior employees may physically contact members of the
management team freely in the case of threats to essential healthcare services.
The alert tree is described below:
7.2
COOP implementation procedure
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The implementation procedure will be tailored along the specific emergency event hence various
procedures may be available for an institution. The following procedure may however be used as
a guide through which various implementation plans for different emergency events may be
developed:
7.2.1 Procedure description
The details provided below regards departmental procedures during the implementation of COOP
in the case of failure to access the healthcare facility, failure to provide healthcare services as a
result of system or equipment breakdown or the failure to provide healthcare services due to a
reduced number of employees. The COOP may be altered based on the causes of the actual
emergency situation as well as the available resources (Virginia Department of Emergency
Management, 2010).
The plan is provided assuming that all personnel are aware of their responsibilities during the
implementation process and that upon implementation, the COOP plan will go a long way in
reducing the losses or effects that may be brought about by the emergency events (Morash,
2013).
7.2.2 Activation and Relocation phase
This phase is headed by the COOP coordinator who updates all key personnel of their
responsibilities during the implementation and assisted by the reconstitution manager.
Preparatory plans to coordinate the COOP implementation process are discussed between team
members. These should be tailored along the specific emergency case and the support functions
necessary for recovery of essential processes e.g. notification of personnel of the emergency
situation and issuance of appropriate instructions (ASPR, 2015).
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The heads of departments should ensure and confirm that are personnel are evacuated from the
healthcare facilities based on the actual COOP event (Clark and Biddinger, 2013). The
reconstitution managers and supervisors are expected to verify personnel contact lists through
physical interaction with employees as well as patients present in the facility at the time. Verified
personnel should then be relocated to an alternative facility location within 12 hours where the
following takes place:
-
The COOP reconstitution manager initiates plans to return essential healthcare functions
back to normal
-
The COOP coordinator provides instructions and guidance to other team members on the
adaptive process to the new location
-
The COOP team collaborates with other relevant stakeholders including the City’s
emergency response team to ensure normalization of both internal and external essential
functions.
7.2.3 Reconstitution phase
During this phase, the reconstitution manager in conjunction with the COOP coordinator should
develop procedures to allow reconstitution of essential functions in the case of an emergency
event. The head of the emergency department may upon the implementation of the COOP and
verification by the COOP coordinator inform the chief executive officer that the threat or
emergency situation has been nullified or fully managed (Clark and Biddinger, 2013).
Resumptions of normal healthcare services may then resume upon approval by the CEO.
The emergency department may review the effectiveness of the COOP plan by analyzing each
step taken and their outcomes (Federal Emergency Management Agency, 2016). A review report
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should then be written by the COOP coordinator and handed over to the facility’s CEO as well as
the executive leadership of Wilmington city.
8.0
Interim Processes
The healthcare facility may also have alternative operations or operations that may be used to
achieve some level of functionality before normalization of normal services. Interim processes are
important in reducing the magnitude of losses especially in the case where essential operations are
completely cut off (Virginia Department of Emergency Management, 2010). These processes are
heavily dependent on the available resources within the healthcare facility as well as the nature of
the emergency event.
The table below should be filled by the COOP team to enable restoration of essential services
effectively. Some examples of interim processes have been provided.
Essential process Emergency event
Interim process
Recovery time
objective
Communications Failure
of
the Use physical contacting methods 48 hours
communication
Adopt use of messengers
network
Use
of
alternative
communication lines such as
fax, pagers and voice lines
Administration
Breakdown
of
and logistics
support system
IT Manually
retrieve
patient 24 hours
records
Use manual register for patient
appointments
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Primary
Reduction
Healthcare
number of employees
delivery
in
16
the Contract temporary healthcare 24 hours
Breakdown
professionals
of Develop a utilization plan for
essential equipment
active essential equipment for
use by the most critical patients
Table 6
9.0
Appendix
Appendix A: Essential functions
Essential
function
Description Key
Vital records
personnel
Systems
equipment
and Recovery Time
Objective
(RTO)
Communications
Patient care unit
Administration
and logistics
Primary
Healthcare
deliver
Operational and
maintenance
functions
Table 7
The above form should be filled out by the COOP coordinator. The time objective provided is
variable and will depend on the level of emergency and available resources to manage the situation.
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References
ASPR (2015). Healthcare COOP & Recovery Planning Concepts, Principles, Templates &
Resources. Retrieved from
http://www.phe.gov/Preparedness/planning/hpp/reports/Documents/hc-coop2-recovery.pdf
Clark, E. M and Biddinger, D. P. (2013). Essential Functions and Considerations for Hospital
Recovery; Emergency Preparedness Bureau. Retrieved from
https://www.nasemso.org/Projects/DomesticPreparedness/documents/Essential-Functions-andConsiderations-of-Hospital-Recovery.pdf
Federal Emergency Management Agency (2016). Continuity of Operations (COOP) Multi-Year
Strategy and Program Management Plan Template Guide. Retrieved from
https://www.fema.gov/media-library-data/1393947474558f38b6ada217b16fc8aa67e207362f6f9/MYSPMP%20Template.pdf
Morash, A. S. (2013). Emergency response and continuity of operations planning – Boston
University. Retrieved from http://www.bu.edu/orc/files/2013/06/BU-COOP.pdf
Virginia Department of Emergency Management (2010). Continuity of Operations (COOP)
Department Plan Template – City of Richmond. Retrieved from
http://www.richmondgov.com/fire/documents/RichmondDepartmentTemplateV2.pdf