CSD Business Continuity Functional template
FUNCTIONAL BUSINESS
CONTINUITY PLAN
FOR
QUEENSLAND HEALTH
CENTRAL STERILIZING
DEPARTMENTS
YOUR HOSPITAL
TITLE
This plan shall be titled and known as the:
“FUNCTIONAL BUSINESS CONTINUITY PLAN FOR QUEENSLAND HEALTH
CENTRAL STERILIZING DEPARTMENT, YOUR 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:
------------------------------------------------
Insert Name
Executive Director – Director of Medical Services, Your Hospital
Insert region Hospital Health Service
Date:
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Table of Contents
N.B. Tables, Apendices, Charts & other attachments may not flow in numerical order. This is due to ensuring they stay the same consistent name as in the Planning BCP while maintaing a practical workflow in event of activation for which this plan will be predominantly used.
2. Pre-Issue Planning – Essential Functions, Activities and Minimum Resources.............. 5
Appendix 8 – Service Agreement / Memorandum of Understanding with ….. ....................... 26
Appendix 9 – Service Agreement / Memorandum of Understanding with ….. ....................... 26
Appendix 10 – Service Agreement / Memorandum of Understanding with ….. ..................... 26
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CHO
CSD
CEO
DON
DTPM
FTE
HPID
HHS
HSPL
MI
MOU
NUM
SA
SOP
SUO
Abbreviations
BCP
BIA
CDB
CHRISP
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 (Hospital and Health Network)
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
Memorandum of Understanding
Nurse Unit Manager
Service Agreement
Standard Operating Procedures
Single Use Only
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Authority and Planning Responsibility
Refer to planning template.
2. Pre-Issue Planning – Essential Functions, Activities and
Minimum Resources
Any headings with no detail will be covered under the full Business Continuity Plan
(planning BCP) and not deemed essential for the use of this Functional Business
Continuity Plan.
All tables and appendices in this Functional BCP should be copied over directly from the planning BCP which holds all the required information for planning & functional activation of the BCP
Essential Functions
See planning BCP
Activation
The decision to activate this Business Continuity Plan (BCP) independently of the
BCP of the Local facility is the responsibility of the DON. Once this decision has been made, the Nurse Manager - Central Sterilizing Departments (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
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. These should be recorded as an Appendix.
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 Nurse
Unit Manager (NUM) - CSD, to determine the best option at the time of disruption.
The options available may include but are not limited to:
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)
Relocating to alternate facilities as arranged in the SA/MOU (if any) & outlined in
Table 7.
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Appendices for Business Continuity Plan for Queensland Health Central sterilizing departments
Table 2 – Business Impact Analysis
Impacts
(Rate 1 to 5)
Essential Business
Function
Highest Impact
(Provide a description of the highest rated impact)
MAO
(Maximum
Acceptable
Outage) e.g Reprocessing of reusable surgical instruments and equipment. (standard sets) e.g. Reprocessing of reusable surgical instruments and equipment. (specialist procedures)
Table 2a – Impact Ratings
Rating Category
1 Insignificant
Description
2
3
Minor
Moderate
4
5
Major
Catastrophic
Internal short term work arounds (to consider if always available to reduce impact rating)
Comments
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Appendices for Business Continuity Plan for Queensland Health Central sterilizing departments
Table 4 – Minimum Staffing Requirements
Essential Business Functions
Current Resource Level
(available to complete
Additional Resource Requirements.
Minimum additional levels required to complete key business processes (we need to consider that we may key business process)
AM PM 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.)
W’end <1 hour
1 - 4 hours
1 Day 2 to 7
Days
1 - 2
Weeks
2-4
Weeks
> 1
Month
Reprocessing of reusable surgical instruments and equipment standard and specialist)
Manual Alternate
Workarounds
(Yes/ No)
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Appendices for Business Continuity Plan for Queensland Health Central sterilizing departments
3. Continuity Plan
Table 6 - Determining Responsibilities and Operational Activities
Functional Areas Position Alternate or Standby
Activation of BCP
Contact key BCP
Key
Responsibility/Activity
Initiate contact with key stakeholders to determine level of activation (appendix 5
& 3)
Make contact with key stakeholders from
Appendix 5 & proceed as directed in Appendix
3 to facilitate smooth activation of CSD BCP
Reports to
Contact CSD Staff
Return to normal operation
Contact staff to advise of alternative work arrangements
Assess functionality & capability of Central sterilizing departments as being able to perform essential functions & notify key stakeholders (appendix
3) of return to normal.
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Appendix 1a – Activity Summary: flow charts
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Chart 1
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Chart 2
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Chart 3
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Chart 4
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Chart 5
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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/MOU) 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/MOU 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 Central sterilizing departments NUM’s of the facilities you have set SA/MOU 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 & other works being undertaken to provide continuity of essential functions.
5. Once CSD is operational to resume all essential functions, cease SA/MOU & 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) iv. Acknowledge what worked well v. Time line of events vi. Conclusion & any recommendations for improvement.
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Appendix 1c
– Operational Checklist
Action
1. Complete & maintain (ongoing outside/prior to activation of the plan
– refer to planning BCP)
2. Contact (upon activation)
Appendix 5
Appendix 2
Special Skills
– Essential Contact List
– Staff Contact, Category Rating &
Reason
To determine fault & begin continuity measures
To respond to required activation needs (such as alternative work arrangements)
3. Activation & Recording of Events (During activation of BCP)
Document which SA/MOU are being utilised & what portion of work is being carried out at each facility.
Maintain a log of inventory out & in, including documentation of processes undertaken at alternate facilities to ensure compliance with standards. Appendix 4a
Document agreements/contracts with other external providers such as transport/freight companies
– Tracking Log
Document steps taken to rectify the issue within
Central sterilizing departments
4. Resume Essential Functions
Inform all Key Stakeholders & Staff that were contacted in step 2 (from Appendix 2 & 5) and cease all SA/MOU with alternate facilities and additional assistance with external stakeholders once Central sterilizing departments is functional to perform essential functions.
Report on the entire process from initial issue through activation of BCP to resumption of essential services. (Include comments/reports from facilities assisting). The severity of the issue will determine the detail of the report.
Reports to go up the chain within the facility & to
CHRISP using template on appendix 4.
To assist with tracking of instruments, accountability of work
To assist with tracking of instruments, accountability of work
To assist with tracking & accountability of transportation
For future reporting needs
Alleviate workload of assisting CSD, return to normal and best practice processes.
To be able to evaluate and possible improvement on the process to share with all Queensland
Health CSD
Done
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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). Please feel free to amend at your discretion per individual requirements.
Area /
Internal /
External
Your
Hospital
Name Position Department/Company Phone
Number
Contact
Priority
Advice
&
Support
Notification
Only
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Area /
Internal /
External
Corporate
Office
Other Qld
Health contacts
Name
External
Contacts
Rosemary
Steinhardt
Position
Sterilizing Program
Manager
CHRISP
Department/Company Phone
Number
332 89767 /
0427672713
Contact
Priority
Advice
&
Support
Notification
Only
2 - 3
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Appendices for Business Continuity Plan for Queensland Health Central sterilizing departments
Appendix 2 – Staff Contact List, Category Rating & Special Skills
Contact made via NUM CSD or delegate. Contact details kept with within HR.
Name Special Skills Category Rating (as per Table 6a)
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Appendices for Business Continuity Plan for Queensland Health Central sterilizing departments
Table 7: Alternative Facilities
Alternate
Location or Facility
Tasks able to be undertaken at this location
Capacity to accept % of normal load
(full service)
%
Ability to reprocess complex sets: (list specialities)
%
%
%
%
%
%
%
%
Please refer to the SA/MOU (if any) for Hours of Operation, and Staffing
Requirements for each facility above.
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Appendices for Business Continuity Plan for Queensland Health Central sterilizing departments
Appendix 5 - Communication Guidance
Clear, concise and consistent message
Clearly define target audience – one message does not fit all.
Good Morning/Afternoon, this is department.
Insert Name from Insert Facility &
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 SA/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 Central sterilizing departments
3.0 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.
Note: Appendix 1c – Operational Checklist includes checks for returning to normal operational mode.
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Appendices for Business Continuity Plan for Queensland Health Central sterilizing departments
Appendix 3a
– Reporting Template
For Impacts 2 or above as per Table 2
Date:
Issue:
Insert Date Location: Insert Facility Name
Brief description of issue. E.g. loss of steam to sterilizers, Power failure.
Contact / Notification: Who: Reason: e.g. to activate BCP, to notify of issue, to request assistance/ activate service agreement
Services Utilised:
Who: Service provided: e.g. equipment transport, 30% sterilization requirements,
50% wash, wrap & pack
How Long: date started
– date finished dd/mm/yy - dd/mm/yy
Rectification Steps: (include any barriers encountered)
Step: e.g. Engineering to look at steam supply
CENTRAL
STERILIZING
DEPARTMENTS back functional:
Service Impact/
Additional Comments: dd/mm/yyyy
Response:
Date full service resumed:
(if not enough space below, please attach additional sheet/s with comments)
Rectification Date: dd/mm/yyyy
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Appendices for Business Continuity Plan for Queensland Health Central sterilizing departments
Appendix 3b
– TRANSIT Log
Instrument Sets or
Single items Sent
Sent To
(facility) with
(transport option)
For
Process
(e.g. washing, sterilizing etc)
Date /
Time sent
& initial
Received by
Date / time
Goods
Sent & initial
Date / time
Goods
Received & initial
Copy of process record
(if applicable) attached to relevant log & initial of staff
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Appendices for Business Continuity Plan for Queensland Health Central sterilizing departments
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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